Using intervention mapping to develop an occupational advice intervention to aid return to work following hip and knee replacement in the United Kingdom.

BACKGROUND: There are increasing numbers of total hip replacements (THR) and total knee replacements (TKR) being performed in patients of working age. Providing patients undergoing TKR and THR with return to work advice might facilitate return to work. The aim of this paper is to report on the process used to systematically develop an occupational advice intervention to be delivered in hospital for those undergoing arthroplasty. METHODS: The six-step Intervention Mapping (IM) approach to development, implementation and evaluation of a theory and evidence-based interventions was followed. This paper reports on the development of the intervention covered by steps 1 to 4 of the IM process. Steps 1-3 gathered data on current practice and barriers to change using a mixed methods approach (cohort study of patients undergoing THR or TKR, stakeholder interviews, survey of practice, evidence synthesis) and provided a theoretical framework for intervention development. Step 4 used information from steps 1-3 in combination with a Delphi consensus process to develop the intervention and the associated tools and materials to facilitate its delivery. RESULTS: The final intervention identified included a number of core principles including: early patient identification; delivery of key information to patients and their employers; assessment and support by a member of the orthopaedic team; procedures for escalation based on patient need; mechanisms to support communication; and training and support for the clinical teams delivering care. A total of 13 patient and 20 staff performance objectives as delivery requirements, were supported by a range of tools, roles and training resources. The intervention addressed outcomes based at the individual and interpersonal levels of the ecological model. CONCLUSIONS: Following the IM approach resulted in a structured and justified occupational intervention for delivery in secondary care for patients undergoing total hip and knee replacement. The feasibility of the intervention will subsequently be tested alongside further investigation to establish its effectiveness and cost-effectiveness.

Managing Employees Undergoing Total Hip and Knee Replacement: Experiences of Workplace Representatives.

Introduction There is little research on return to work (RTW) from a workplace perspective following hip and knee replacement (THR/TKR) despite employers and other workplace personnel having a key role. Our aim was to explore the experiences of individuals in the workplace in managing employees undergoing THR/TKR. Methods Employers and other workplace representatives from a cross-section of employment sectors and sizes, with experience of managing employees undergoing THR/TKR in the previous 12 months, were recruited. Interviewees included small business owners, line managers, colleagues, human resources managers and occupational health advisers. Semi-structured, qualitative interviews were conducted and data were analysed thematically. Results Twenty-five individuals were interviewed. The main themes identified were accommodating the employee, and barriers and facilitators to RTW. Accommodations included changes to the work environment, amended duties, altered hours, changed roles and colleague support. Perceived barriers and facilitators to RTW included the role of GPs and occupational health, surgical issues, characteristics of the work environment and of employees. Conclusions Employers are motivated to effect supported RTW for employees undergoing THR/TKR but have insufficient guidance. Strategies are required to signpost employers to existing RTW advice, and to develop recommendations specific to lower limb arthroplasty. Communication between medical practitioners and employers should be facilitated in order to enhance the RTW experience of individuals undergoing THR/TKR.

Development of an occupational advice intervention for patients undergoing lower limb arthroplasty (the OPAL study).

BACKGROUND: There are an increasing number of patients of working age undergoing hip and knee replacements. Currently there is variation in the advice and support given about sickness absence, recovery to usual activities and return to work after these procedures. Earlier, sustainable, return to work improves the health of patients and benefits their employers and society. An intervention that encourages and supports early recovery to usual activities, including work, has the potential to reduce the health and socioeconomic burden of hip and knee replacements. METHODS/DESIGN: A two-phase research programme delivered over 27 months will be used to develop and subsequently test the feasibility of an occupational advice intervention to facilitate return to work and usual activities in patients undergoing lower limb arthroplasty. The 2 phases will incorporate a six-stage intervention mapping process: Phase 1: Intervention mapping stages 1-3: 1 Needs assessment (including rapid evidence synthesis, prospective cohort analysis and structured stakeholder interviews) 2 Identification of intended outcomes and performance objectives 3 Selection of theory-based methods and practical strategies Phase 2: Intervention mapping stages 4-6: 4 Development of components and materials for the occupational advice intervention using a modified Delphi process 5 Adoption and implementation of the intervention 6 Evaluation and feasibility testing The study will be undertaken in four National Health Service (NHS) hospitals in the United Kingdom and two Higher Education Institutions. DISCUSSION: OPAL (Occupational advice for Patients undergoing Arthroplasty of the Lower limb) aims to develop an occupational advice intervention to support early recovery to usual activities including work, which is tailored to the requirements of patients undergoing hip and knee replacements. The developed intervention will then be assessed with a specific focus on evaluating its feasibility as a potential trial intervention to improve speed of recovery to usual activities including work. TRIAL REGISTRATION: The study was registered retrospectively with the International Standard Randomised Controlled Trials Number (ISRCTN): 27426982 (Date 20/12/2016) and the International prospective register of systematic reviews (PROSPERO): CRD42016045235 (Date 04/08/2016).

Exploring the barriers to and facilitators of implementing research into practice.

District and community nursing roles have changed rapidly in recent years. Community nurses are increasingly being tasked with carrying out multiple roles, which require them to put research into practice and use evidence-based tools and interventions. The implementation of interventions and tools needs to be developed from empirical research, requiring evidence, to be translated into practice. However, this process may be compromised or enhanced by a number of factors. This exploratory, descriptive qualitative study sought to identify barriers and facilitators to community nurses implementing research into practice. Four focus groups were conducted with registered community nurses and district nurses (n=22). Analysis identified four main themes: keeping up to date with evidence; using a clinical tool; education/training and implementation. Findings suggest that there are barriers at a personal, professional and organisational level. Strategies are suggested to overcome these obstacles.

Return-to-work outcomes and usefulness of actual fit notes received by employers.

BACKGROUND: GPs can use the fit note to advise that a patient 'may be fit' or is 'not fit' for work. Previous employer-based research on the fit note is largely qualitative and based on general perceptions and past experience. Knowledge of the return-to-work outcomes and usefulness of actual fit notes is needed to strengthen the evidence-base and inform practice. OBJECTIVE: To investigate the return-to-work outcomes of fit notes issued to employed patients, and their employers' opinions as to the usefulness of each note. METHODS: Participating organizations collecting fit notes were asked to rate the outcome and usefulness of each fit note via postal questionnaires. Quantitative data were analysed descriptively; qualitative data were analysed using thematic content analysis. RESULTS: Five hundred and sixteen questionnaires were posted, with a 97% return rate (n=498). More than 80% of employees (n=44) returned to work after the expiry date of a 'may be fit' note compared with 43% (n=167) of those issued with a 'not fit' note. Fit notes were considered more useful if they provided information on the condition and its effect on the employee's ability to work, if they stated whether or not the employee needed reassessment and if clear advice regarding return-to-work had been provided. CONCLUSIONS: 'May be fit' notes are useful in helping employees return to work. However, this option is infrequently used, and the completion and content of many fit notes does not meet employers' needs. These factors need to be urgently addressed if the fit note is to reach its full potential.

Recommendations to facilitate the ideal fit note: are they achievable in practice?

BACKGROUND: Although the UK fit note has been broadly welcomed as a tool to facilitate return to work, difficulties and uncertainties have resulted in wide variation in its use. Agreement on what constitutes the 'ideal' fit note from the perspective of all stakeholders is needed to inform best practice. A recent Delphi study conducted by the authors reached consensus on 67 recommendations for best practice in fit note use for employed patients. However, such recommendations are not necessarily followed in practice. The purpose of this study was therefore to investigate the perceived achievability of implementing these Delphi recommendations with a further reference panel of stakeholders. METHODS: Potential participants were identified by the research team and study steering group. These included representatives of employers, government departments, trades unions, patient organisations, general and medical practitioners and occupational health organisations who were believed to have the knowledge and experience to comment on the recommendations. The consensus Delphi statements were presented to the participants on-line. Participants were invited to comment on whether the recommendations were achievable, and what might hinder or facilitate their use in practice. Free text comments were combined with comments made in the Delphi study that referred to issues of feasibility or practicality. These were synthesised and analysed thematically. RESULTS: Twelve individuals representing a range of stakeholder groups participated. Many of the recommendations were considered achievable, such as improved format and use of the electronic fit note, completion of all fields, better application and revision of guidance and education in fit note use. However a number of obstacles to implementation were identified. These included: legislation governing the fit note and GP contracts; the costs and complexity of IT systems and software; the limitations of the GP consultation; unclear roles and responsibilities for the funding and delivery of education, guidance and training for all stakeholders, and the evaluation of practice. CONCLUSIONS: This study demonstrated that although many recommendations for the ideal fit note are considered achievable, there are considerable financial, legal, organisational and professional obstacles to be overcome in order for the recommendations to be implemented successfully.

Communicating with employers: experiences of occupational therapists treating people with musculoskeletal conditions.

PURPOSE: Many employed people with musculoskeletal conditions rely on healthcare practitioners, including occupational therapists, for work-related advice and support. Good communication between healthcare practitioners and employers is considered vital in facilitating work retention and return to work. The purpose of this study was to explore the experiences of occupational therapists in communicating with patients' employers. METHODS: Qualitative data were collected from the responses of occupational therapists to ten statements/open questions in a questionnaire survey of UK occupational therapists. Data were copied verbatim into word documents and analysed thematically. RESULTS: A total of 649 comments were made by 143 respondents. Five themes were identified that were associated with communicating with employers: patient-dependent; employer-dependent; therapist-dependent; extrinsic factors; methods of communication. CONCLUSION: This study has identified that communication between occupational therapists and employers is influenced by a number of factors, including those which are outside the therapists' control. These need to be acknowledged and addressed by therapists, their professional organisation, employers, commissioners, therapy service managers, educators and employees in order to support return-to-work and work retention of people with musculoskeletal conditions.

Individual work support for employed patients with low back pain: a randomized controlled pilot trial.

OBJECTIVE: To investigate the feasibility and effectiveness of individual work support for employed patients with low back pain. DESIGN: Pilot randomized controlled trial of a 16-week vocational intervention with six-month follow-up. SETTING: Community/outpatient. PARTICIPANTS: Fifty-one employed participants concerned about their ability to work due to low back pain. Outcome data was obtained for 38 participants at six-month follow-up. INTERVENTIONS: The intervention group received up to eight individually targeted vocational sessions in conjunction with group rehabilitation for low back pain. The control group received group rehabilitation. OUTCOME MEASURES: The feasibility of the intervention was assessed by the recruitment rate, drop-out and loss to follow-up of the participants and the content and delivery of the intervention as recorded by the researcher. The primary outcome measure was perceived work ability. RESULTS: Seventy-three participants were referred to the study over six months. Eighty-seven individual work support sessions were delivered. Thirty-one participants (61% of those retained in the study) attended more than half of the group rehabilitation sessions. The intervention was influenced by the uptake of group rehabilitation, the willingness of the participants to involve their workplace and of their workplace to involve the research therapist. The effect of the intervention on work ability was equivocal. CONCLUSIONS: Although it was possible to recruit participants and to deliver the intervention, considerable methodological problems were identified. However, even if these were addressed, the impact of such interventions is likely to be limited unless there is an integrated approach between healthcare, employers and employees. Further research is required to evaluate work-focused interventions with this client group.

What do we tell patients about elective total hip replacement in the UK? An analysis of patient literature.

BACKGROUND: Although hip information literature is given to people following total hip replacement (THR) almost routinely, little evaluation has been conducted on it to date. Our aim was therefore to analyse and evaluate the literature provided to patients by occupational therapists concerning elective hip surgery in the UK. METHODS: This was a pragmatic, descriptive analysis of information leaflets routinely given to patients undergoing primary total hip replacement (THR). The literature was collected as part of a national survey of occupational therapy practice. In the absence of a suitable evaluation tool, the patient leaflets were compared using a checklist devised by the researchers. The three areas of interest were: accessibility including presentation of information, breadth of information covered and specific activities of daily living described. RESULTS: 111 information leaflets and booklets were examined. These ranged from hospital publications which were professionally printed to those produced by individual departments. There was a variation in the readability of the leaflets ranging from 13% to 83%; the mean was 45% (SD 15). There was also variation in the content ranging from those covering surgery and possible complications, to those including diet and hip exercises. The most commonly covered activity of daily living was advice on sitting (99; 89%); the least commonly covered was work (26; 23%). Only 3 (2.7%) booklets had involved patients in their production and only 22 (20%) signposted obtaining information in another language or in Braille. CONCLUSIONS: There was a range of literature in terms of presentation and content given to people who had a total hip replacement (THR). Although some booklets and leaflets scored highly, some did not meet basic standards such as providing contact details for help, using good quality diagrams, suggesting further reading or involving patients in their design. These results highlight important and fundamental deficiencies in the literature routinely provided.

Returning to work after stroke: perspectives of employer stakeholders, a qualitative study.

PURPOSE: More than 40 % of working age adults with stroke fail to return to work. The work context is a key factor in return to work, but little is known about the experiences of employers in supporting employees with stroke. The aim of this study was to explore return to work after stroke from the employer perspective, to identify key features associated with success and to seek participants' views regarding the role of healthcare in return to work. METHODS: Data was gathered through 18 semi-structured interviews with employer stakeholders and included small business owners, line managers, human resources and occupational health staff. Data was analysed thematically. RESULTS: The main themes identified were: the impact of stroke on the employer, characteristics of the employee, communication, knowledge and information, experience of other stakeholders, integrating healthcare in return to work. CONCLUSION: Employers face complex emotional and practical issues when helping an employee return to work after stroke, for which many lack knowledge and experience. The range and quality of support networks that they access is variable and advice and support from clinicians is welcomed. Further research is necessary to investigate how such support could be funded and integrated within existing service provision.

Clinicians' experiences of discontinuing routine hip precautions following total hip replacement surgery: a qualitative analysis.

PURPOSE: Hip precautions are routinely provided in the UK, despite evidence suggesting that they are no longer needed. A change in practice was introduced into an orthopaedic service whereby the provision of routine hip precautions was discontinued for selected individuals receiving a primary total hip replacement. The change involved implementing a new regime of "no precautions" which was facilitated using a number of key strategies. The aim of this study was to explore the experiences of clinicians associated with the change in practice. MATERIAL AND METHODS: Individual semi-structured interviews were conducted with clinicians who had experience of delivering both hip precautions and no hip precaution regimes. Data were analysed thematically. RESULTS: Ten orthopaedic staff (two senior occupational therapists, one occupational therapy support worker, three senior physiotherapists, two surgeons, and two senior nurses) were interviewed. Three main themes were identified: changes experienced, perceptions of the new regime, and challenges experienced. CONCLUSION: Several barriers and facilitators to the successful changeover were identified. Successful strategies in changing practice included assigning "Hip Champions", staff education and targeted training. It is proposed that holding multidisciplinary education and training would be the ideal model.Implications for rehabilitationKey strategies for changing practice were educating staff and providing targeted training.Multidisciplinary training might prevent discrepancies in the advice given to patients.Appointing "Hip Champions" provided clear role models and enabled new clinical behaviours to be enforced.

Total hip and knee replacement and return to work: clinicians' perspectives.

PURPOSE: An ageing workforce means that our understanding of return to work following total hip and knee replacement is of increasing importance. The purpose of this qualitative study was to explore the views and experiences of clinicians in treating working patients undergoing total hip or knee replacement. MATERIALS AND METHODS: We conducted semi-structured interviews in primary and secondary National Health Service care using framework methodology. A total of 40 interviews were conducted. Participants included 12 hospital-based Allied Health Professionals and nurses, 12 orthopedic surgeons, and 16 General Practitioners. Data were analyzed thematically. RESULTS: A key theme concerned participants' perceptions and experiences around the process and practice of listing working patients for total hip or knee replacement. Four sub-themes were identified; the perceived likelihood of listing employed patients for surgery, expectations and outcomes of surgery, the impact of work issues, and referral procedures and waiting lists. CONCLUSIONS: Decisions around listing working patients for total hip and knee replacement are complex and difficult. Clinicians need to consistently consider patients' work issues, and to be supported in this by appropriate commissioning and service delivery decisions. Further research is indicated to better understand the work-related expectations and anticipated outcomes of both patients and clinicians, and the optimum timing of surgery to maintain and improve patients' work performance.Implications for rehabilitationClinicians need to consistently consider patients' work issues, and current evidence, in their consultations and decisions regarding total hip and knee replacement.Clinical practice should reflect the growing proportion of working patients undergoing total hip and knee replacement, and routinely measure work outcomes.Changes are required at commissioning and service levels to support clinicians in changing their practice with this patient population.

Hip precautions after total hip replacement and their discontinuation from practice: patient perceptions and experiences.

BACKGROUND: Hip precautions are routinely provided to reduce the risk of dislocation following total hip replacement despite evidence suggesting they provide no additional benefit and may, actually, impede recovery. Our aim was to report the views of patients who had been recruited into a trial comparing outcomes in participants who were prescribed hip precautions with those who were not. METHODS: Semi-structured interviews were conducted. Topics explored included experiences and opinions of the service (either hip precautions or no hip precautions), information offered, and equipment provided. Thematic analysis was used to identify and report themes. RESULTS: Six themes were identified: perceived justification, and advantages and disadvantages for the postoperative recovery regime prescribed, perceived risk, and fear of dislocation, adherence to the postoperative regime prescribed, and experiences of adaptive equipment. CONCLUSIONS: Participants who received hip precautions had mixed views about their use: some felt they were restrictive whilst others believed they provided reassurance. Participants who did not receive hip precautions were less anxious about dislocating their hip but were unsure how to progress their rehabilitation. The discontinuation of precautions may decrease patients' fears about dislocation but more guidance from rehabilitation staff about how to move safely during recovery is required.Implications for rehabilitationHip precautions may unnecessarily exacerbate patients' anxieties and fear about dislocation following total hip replacement.Hip precautions impact on patients' recovery both physically and psychologically.Patients should be advised about moving and returning to activities following total hip replacement, whether they receive hip precautions or not.

Evaluation of hip precautions following total hip replacement: a before and after study.

PURPOSE: To evaluate the effect of hip precautions following total hip replacement (THR) by comparing outcomes of patients who received hip precautions with those who did not. METHODS: Before (phase 1) and after (phase 2) study with two consecutive cohorts of patients. In phase 1, patients were strictly educated about hip precautions. In phase 2, patients were not advised about precautions but encouraged to move as able. The primary outcome was the Oxford Hip Score (measuring pain and function) at three months. Secondary outcomes included Oxford Hip Score, activities of daily living (ADLs) (Nottingham Extended Activities of Daily Living), sleep (Pittsburgh Sleep Quality Index), mood (Hospital Anxiety and Depression Scale), and quality of life (QoL) (EQ-5 D). RESULTS: A total 237 participants successfully underwent THR surgery, 118 participants in phase 1 and 119 in phase 2. At three months postoperatively, participants had significantly equivalent Oxford Hip Scores (MD= -0.82, 95% CI: -2.64 to 1.00). No significant differences between the groups were observed at six weeks and three months postoperatively for secondary outcomes. CONCLUSIONS: Patients recovered at a similar rate regardless of whether they received hip precautions or not, with no increase in complications observed. The findings lend evidence to support decision-making around the removal of precautions.Implications for rehabilitationThe use of no hip precautions resulted in no additional benefit following primary total hip replacement surgery in terms of functional recovery.Patients who were not prescribed precautions had significantly less pain and greater function during the first week after surgery.Total hip replacement patients had similar outcomes at six weeks and three months postoperatively regardless of whether they received hip precautions or not.The study provides evidence to suggest that hip precautions may not be needed routinely following elective primary total hip replacement.

Work problems due to low back pain: what do GPs do? A questionnaire survey.

BACKGROUND: Low back pain can affect work ability and remains a main cause of sickness absence. In the UK the GP is usually the first contact for patients seeking health care. The UK government intends that the GP will continue to be responsible for sickness certification and work advice. This role requires a considerable level of understanding of work rehabilitation, and effective communication between GPs, patients, employers and therapists. OBJECTIVES: The aim of this study was to identify GPs' current practice in managing patients whose ability to work is affected by low back pain, and their perception of the support services required. METHOD: A postal questionnaire of 441 GPs in the South Nottinghamshire area of the UK was carried out. Areas covered included referral patterns, sickness certification, and communication with therapists and employers. RESULTS: There was a 54.6% response rate. The majority of GPs (76.8%) reported that they did not take overall responsibility for managing the work problems of patients arising from low back pain. Few 'mainly agreed' that they initiated communication with employers (2.5%) and/or therapists (10.4%) regarding their patients' work. CONCLUSION: The results of this study demonstrate that most GPs do not readily engage in vocational rehabilitation and do not initiate contact with employers or other health care practitioners regarding patients' work problems. Thus the current government expectation that GPs are able to successfully manage this role may be unrealistic; considerable training and a change in the GPs' perception of their role will be required.

Staying at work with back pain: patients' experiences of work-related help received from GPs and other clinicians. A qualitative study.

BACKGROUND: Low back pain commonly affects work ability, but little is known about the work-related help and advice that patients receive from GPs and other clinicians. The purpose of this study was to explore the experiences of employed people with back pain and their perceptions of how GPs and other clinicians have addressed their work difficulties. METHODS: A qualitative approach with thematic analysis was used. Individual interviews were carried out with twenty-five employed patients who had been referred for back pain rehabilitation. All had expressed concern about their ability to work due to low back pain. RESULTS: The perception of the participants was that GPs and other clinicians had provided little or no work-focused guidance and support and rarely communicated with employers. Sickness certification was the main method that GPs used to manage participants' work problems. Few had received assistance with temporary modifications and many participants had remained in work despite the advice they had received. There was little expectation of what GPs and other clinicians could offer to address work issues. CONCLUSIONS: These findings question the ability of GPs and other clinicians to provide work-focused support and advice to patients with low back pain. Future research is recommended to explore how the workplace problems of patients can be best addressed by health professionals.

Low back pain patients' experiences of work modifications; a qualitative study.

BACKGROUND: Research indicates that work modifications can reduce sickness absence and work disability due to low back pain. However, there are few studies that have described modified work from the perspective of patients. A greater understanding of their experiences may inform future workplace management of employees with this condition. METHODS: Individual semi-structured interviews were conducted with twenty-five employed patients who had been referred for back pain rehabilitation. All had expressed concern about their ability to work due to low back pain. Data was analysed thematically. RESULTS: Many participants had made their own work modifications, which were guided by the extent of control they had over their hours and duties, colleague support, and their own beliefs and attitudes about working with back pain. A minority of the participants had received advice or support with work modifications through occupational health. Access to these services was limited and usually followed lengthy sickness absence. Implementation largely rested with the manager and over-cautious approaches were common. CONCLUSIONS: There was little evidence of compliance with occupational health guidance on modified work. There appears to be insufficient expertise among managers and occupational health in modifying work for employees with low back pain and little indication of joint planning. On the whole, workers make their own modifications, or arrange them informally with their manager and colleagues, but remain concerned about working with back pain. More effective and appropriate application of modifications may increase employees' confidence in their ability to work.

What concerns workers with low back pain? Findings of a qualitative study of patients referred for rehabilitation.

INTRODUCTION: Health and workplace strategies to address work loss and sickness absence due to low back pain are urgently required. A better understanding of the experiences of those struggling to stay at work with back pain may help clinicians and employers with their treatment and management approaches. METHODS: A qualitative approach using thematic analysis was used. Individual semi-structured interviews were conducted with a convenience sample of 25 low back pain patients who had been referred for multidisciplinary back pain rehabilitation. All were in employment and concerned about their ability to work due to low back pain. Initial codes were identified and refined through constant comparison of the transcribed interview scripts as data collection proceeded. Themes were finally identified and analysed by repeated study of the scripts and discussion with the research team. FINDINGS: Five main themes were identified: justifying back pain at work; concern about future ability to retain work; coping with flare-ups; reluctance to use medication; concern about sickness records. CONCLUSIONS: In this study, workers with low back pain remained uncertain of how best to manage their condition in the workplace despite previous healthcare interventions and they were also concerned about the impact back pain might have on their job security and future work capacity. They were concerned about how back pain was viewed by their employers and co-workers and felt the need to justify their condition with a medical diagnosis and evidence. Clinicians and employers may need to address these issues in order to enable people to continue to work more confidently with back pain.

Development of an occupational advice intervention for patients undergoing elective hip and knee replacement: a Delphi study.

OBJECTIVE: To obtain consensus on the content and delivery of an occupational advice intervention for patients undergoing primary hip and knee replacement surgery. The primary targets for the intervention were (1) patients, carers and employers through the provision of individualised support and information about returning to work and (2) hospital orthopaedic teams through the development of a framework and materials to enable this support and information to be delivered. DESIGN: Modified Delphi study as part of a wider intervention development study (The Occupational advice for Patients undergoing Arthroplasty of the Lower limb (OPAL) study: Health Technology Assessment Reference 15/28/02) (ISRCTN27426982). SETTING: Five stakeholder groups (patients, employers, orthopaedic surgeons, general practitioners, allied health professionals and nurses) recruited from across the UK. PARTICIPANTS: Sixty-six participants. METHODS: Statements for the Delphi process were developed relating to the content, format, delivery, timing and measurement of an occupational advice intervention. The statements were based on evidence gathered through the OPAL study that was processed using an intervention mapping framework. Intervention content was examined in round 1 and intervention format, delivery, timing and measurement were examined in round 2. In round 3, the developed intervention was presented to the stakeholder groups for comment. CONSENSUS: For rounds 1 and 2, consensus was defined as 70% agreement or disagreement on a 4-point scale. Statements reaching consensus were ranked according to the distribution of responses to create a hierarchy of agreement. Round 3 comments were used to revise the final version of the developed occupational advice intervention. RESULTS: Consensus was reached for 36 of 64 round 1 content statements (all agreement). In round 2, 13 questions were carried forward and an additional 81 statements were presented. Of these, 49 reached consensus (44 agreement/5 disagreement). Eleven respondents provided an appraisal of the intervention in round 3. CONCLUSIONS: The Delphi process informed the development of an occupational advice intervention as part of a wider intervention development study. Stakeholder agreement was achieved for a large number of intervention elements encompassing the content, format, delivery and timing of the intervention. The effectiveness and cost-effectiveness of the developed intervention will require evaluation in a randomised controlled trial. TRIAL REGISTRATION NUMBER: International Standard Randomised Controlled Trials Number Trial ID: ISRCTN27426982.

Occupational advice to help people return to work following lower limb arthroplasty: the OPAL intervention mapping study.

BACKGROUND: Hip and knee replacements are regularly carried out for patients who work. There is little evidence about these patients' needs and the factors influencing their return to work. There is a paucity of guidance to help patients return to work after surgery and a need for structured occupational advice to enable them to return to work safely and effectively. OBJECTIVES: To develop an occupational advice intervention to support early recovery to usual activities including work that is tailored to the requirements of patients undergoing hip or knee replacements. To test the acceptability, practicality and feasibility of this intervention within current care frameworks. DESIGN: An intervention mapping approach was used to develop the intervention. The research methods employed were rapid evidence synthesis, qualitative interviews with patients and stakeholders, a prospective cohort study, a survey of clinical practice and a modified Delphi consensus process. The developed intervention was implemented and assessed during the final feasibility stage of the intervention mapping process. SETTING: Orthopaedic departments in NHS secondary care. PARTICIPANTS: Patients who were in work and intending to return to work following primary elective hip or knee replacement surgery, health-care professionals and employers. INTERVENTIONS: Occupational advice intervention. MAIN OUTCOME MEASURES: Development of an occupational advice intervention, fidelity of the developed intervention when delivered in a clinical setting, patient and clinician perspectives of the intervention and preliminary assessments of intervention effectiveness and cost. RESULTS: A cohort study (154 patients), 110 stakeholder interviews, a survey of practice (152 respondents) and evidence synthesis provided the necessary information to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 13 patient and 20 staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. Feasibility was assessed for 21 of the 26 patients recruited from three NHS trusts. Adherence to the defined performance objectives was 75% for patient performance objectives and 74% for staff performance objectives. The intervention was generally well received, although the short time frame available for implementation and concurrent research evaluation led to some confusion among patients and those delivering the intervention regarding its purpose and the roles and responsibilities of key staff. LIMITATIONS: Implementation and uptake of the intervention was not standardised and was limited by the study time frame. Evaluation of the intervention involved a small number of patients, which limited the ability to assess it. CONCLUSIONS: The developed occupational advice intervention supports best practice. Evaluation demonstrated good rates of adherence against defined performance objectives. However, a number of operational and implementation issues require further attention. FUTURE WORK: The intervention warrants a randomised controlled trial to assess its clinical effectiveness and cost-effectiveness to improve rates and timing of sustained return to work after surgery. This research should include the development of a robust implementation strategy to ensure that adoption is sustained. STUDY REGISTRATION: Current Controlled Trials ISRCTN27426982 and PROSPERO CRD42016045235. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 45. See the NIHR Journals Library website for further project information.

Hip and knee replacements are regularly carried out for patients who work. There is a lack of evidence about these patients' needs and how they return to work. Guidance to enable return to work after surgery is limited. There is, therefore, a need for structured occupational advice to help these patients. The aim of this project was to develop a multidisciplinary occupational advice intervention for this patient population and assess if it could be delivered. The study also aimed to make recommendations about its further assessment in a clinical trial. The study combined different methods of research (quantitative and qualitative) to identify the population likely to benefit, their current care, and the outcomes important to patients and health-care professionals. All of the information gathered was mapped through a framework (intervention mapping), which included a consensus process with stakeholders to develop the intervention. The intervention delivery was assessed for a small number of patients across orthopaedic departments, employer organisations and primary care networks. The study involved 154 patients, 110 stakeholders (general practitioners, surgeons, employers and health professionals/nurses) and a survey of current care (152 respondents) to develop the intervention. The intervention included information resources, a personalised return-to-work plan and co-ordination from the health-care team to support the delivery of 33 patient and staff performance objectives. To support delivery, a range of tools (e.g. occupational checklists, patient workbooks and employer information), roles (e.g. return-to-work co-ordinator) and training resources were created. The intervention was assessed in 26 patients and staff, and showed high rates of adherence to the defined performance objectives. The overall results demonstrated that the occupational advice intervention developed for hip and knee replacement patients is deliverable. The intervention warrants further research to assess its clinical effectiveness and cost-effectiveness as a tool to improve rates and timing of sustained return to work after surgery.