Search results
Electronic bibliographic database searches yielded 1219 publications, of which 49 were considered potentially relevant and retrieved in full text for further review. Twenty-three publications were excluded because the studies did not examine implementation strategies or include implementation outcomes. Others had the wrong population, article type, or rehabilitation discipline. Ultimately, 26 studies were included, as shown by the selection process illustrated in Figure 2. Twenty-six relevant publications were identified, describing 48 out of 73 discrete implementation strategies defined by Powell et al. (27). The publications identified also describe and include implementation outcomes as defined by Procter et al. (28).
Study Inclusion
The full spectrum of studies examining implementation strategies and outcomes was published between 2005 and 2020 and all within the last ten years except one. Table 1 demonstrates that the included studies were conducted throughout the Americas, Europe, Australia, and Africa. Several research designs were noted among the studies, with most research designs being longitudinal, as demonstrated in Table 1. All 26 studies included occupational therapy practitioners (consisting of occupational therapists and occupational therapy assistants) implementing interventions and assessments targeting adults, 19 years old and older, in stroke rehabilitation.
Half of the studies only implemented interventions, while the remaining studies implemented some combination of assessments (screenings, protocols, guideways, and pathways) and interventions. The studies were conducted with occupational therapy practitioners practicing in several healthcare settings, including acute care, inpatient rehabilitation, skilled nursing, outpatient, community, and long-term care. However, three of the studies implemented EBP aimed at occupational therapists working in any healthcare setting and was provided either at an off-site location (36) or non-physical (37) or virtual (38) environment. None of the studies included EBP being implemented in the long-term acute care hospital or hospice healthcare settings to the authors' knowledge.
Synthesis Summary
Primary research question: The first question of this scoping review addressed what implementation strategies occupational therapy researchers have used to support the uptake of interventions and assessments in stroke rehabilitation. The included studies collectively used 48 of the 73 discrete implementation strategies in the ERIC project compilation, as shown in Figure 3. The two most used discrete strategies were [31] Distribute educational materials (36, 38-47) and [4] Assess for readiness & identify barriers & facilitators (34, 38, 40, 42-48, 54), which were implemented each by 11 studies as shown in Figure 3. Regarding the latter strategy, only two of the 11 studies (45, 46) assessed for readiness and identified barriers & facilitators. The remaining nine studies only identified barriers & facilitators. The second most utilized discrete strategy was [16] Conduct educational outreach visits implemented by ten studies (36, 39, 41, 43, 45, 46, 48-51). Other frequently used discrete strategies include [19] Conduct ongoing training, [5] Audit & provide feedback, and [29] Develop educational materials, each of which was implemented in eight of the studies.
None of the studies implemented discrete strategies across all the implementation strategy clusters. Table 1 shows that one study (44) did utilize at least one strategy addressing seven out of the nine clusters and two studies (51, 52) did the same with six out of nine clusters. Twenty-three out of 26 studies implemented discrete strategies within the train and educate stakeholders cluster. The discrete implementation strategy utilized the most within this cluster was [31] Distribute educational materials. The studies also frequently utilized discrete implementation strategies from the following two clusters: use evaluative and iterative strategies and develop stakeholder interrelationships. Seventeen studies implemented strategies in the evaluative and interactive strategies cluster (40, 42, 44-49, 51-59), with [4] Assess for readiness & identify barriers & facilitators being implemented the most within this cluster. Discrete strategies from the develop stakeholder relationships cluster were used in 12 studies (37, 39, 40, 43, 44, 46, 49, 50, 52, 56, 60, 61), with [35] Identify & prepare champions being implemented the most with 7 studies (39, 43, 44, 46, 49, 56, 61).
The same strategies were primarily implemented across the different studies in the following three clusters: provide interactive assistance, adapt and tailor to context, and support clinicians. In the provide interactive assistance cluster, four out of eight studies used [33] Facilitation and three out of eight studies used [54] Provide local technical assistance. Six studies utilized strategies from the adapt and tailor to context cluster. The discrete strategy [51] Promote adaptability was used in four of six studies, and three of the six studies implemented [63] Tailor strategies. Among the eight studies that implemented discrete strategies categorized in the support clinicians cluster, only two different discrete strategies were used. The strategy, [58] Remind clinicians, was almost exclusively used, with seven out of eight studies only implementing this strategy. The one remaining study utilized the discrete strategy [30] Develop resource sharing agreements.
The three implementation clusters from which the studies implemented the least number of discrete strategies were the clusters utilize financial strategies, change infrastructure, and engage consumers. Only one study, (44), implemented strategies from utilize financial strategies, two studies (44, 51) utilized a strategy from change infrastructure, and two studies (51, 52) used at least one strategy in the engage consumers cluster as shown in Table 1. The two discrete implementation strategies used within the cluster utilize financial strategies were [2] Alter incentive/allowance structure and [34] Fund & contract for the clinical innovation. The two discrete strategies implemented from the cluster, change infrastructure, were [44] Mandate change and [11] Change physical structure & equipment. The same occurs in the engage consumers cluster with the implementation of two discrete strategies – [41] Involve patients/consumers & family members and [50] Prepare patients/consumers to be active participants.
Secondary research question. This scoping review's second question addressed what outcomes have been measured to determine stroke rehabilitation implementation strategies' effectiveness. The implementation outcome measured the most was adoption, which was evaluated in 21 out of 26 studies (36-38, 40-46, 48-50, 52, 54-56, 58-61). The second implementation outcome most frequently measured was fidelity with ten studies (41, 42, 47, 50, 51, 53, 55, 57, 58, 60), as shown in Table 1. Fifteen studies measured two implementation outcomes, and eight studies measured one outcome. Among those eight studies, either adoption or fidelity was the only outcome measured. Three of the 26 studies measured more than two outcomes, with two studies (44, 45) measuring three and the remaining study (37) measuring four. While none of the studies measured the outcome of cost, the least measured outcomes were penetration and sustainability. Table 1 shows that one study (44) measured both outcomes.
Influence of implementation strategies. The findings from studies examining the effect of implementation strategies on implementation outcomes were generally mixed. While 11 studies deployed strategies that led to improved implementation outcomes, 13 studies led to inconclusive results. For instance, McEwen et al. (43) developed a multifaceted implementation strategy that involved conducting educational meetings, providing ongoing education, appointing evidence champions, distributing educational materials, and reminding clinicians to implement evidence in practice. These strategies led to increased adoption of their target EBP, the Cognitive Orientation to daily Occupational Performance (CO-OP) treatment approach, suggesting the multifaceted strategy was effective. Alternatively, Salbach and colleagues (46) examined the impact of an implementation strategy consisting of educational meetings, evidence champions, educational materials, local funding, and implementation barrier identification that pertained to stroke guideline adoption. However, these strategies only led to the increased adoption of two out of 18 recommendations described in the stroke guidelines.
Levac et al. (61) also deployed a combination of educational meetings, dynamic training, reminders, and expert consultation to increase the use of virtual reality therapy with stroke survivors, yet found these combined strategies did not lead to an increase in virtual reality adoption among practitioners serving stroke survivors.
Use of theories, models, and frameworks. Notably, of the 26 included articles, 12 articles explicitly stated using a theory, model, or framework (TMF) guiding the intervention utilized in the article (findings summarized in Table 2). The most common supporting TMF employed among the articles was the Knowledge-to-Action framework (n=5). Other TMFs included class theories such as the Behavior Change Wheel (n=3) and Theory of Planned Behavior (n=1). Determinant frameworks represented included the Consolidated Framework for Implementation Research (CFIR) (n=1), the Theoretical Domains Framework (n=1), and the integrated-Promoting Action on Research Implementation in Health Services (iPARIHS) framework (n=1). Two studies applied the Normalization Process Theory. No implementation evaluation frameworks were utilized (such as Reach, Efficacy, Adoption, Implementation, Maintenance (RE-AIM) or Implementation Outcomes Framework) or implementation process models (such as Dynamic Sustainability/Adaptation, Practical, Robust Implementation and Sustainability Model (PRISM), Exploration, Adoption/Preparation, Implementation, Sustainment (EPIS), or Quality Implementation). A select number of studies
described the components of their implementation strategies in accordance with reporting guidelines, including the Template for Intervention Description and Replication (TIDieR) checklist (n=2), the Standards for Quality Improvement Reporting Excellence (SQUIRE) (n=1), and Standards for Reporting Implementation studies (StaRI) (n=1), but did not explicitly mention the use of an implementation framework to guide the intervention.