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

The Needs and Experiences of Patients Returning to Work After Total Knee Arthroplasty and Total Hip Arthroplasty: A Systematic Review and Meta-Synthesis

OBJECTIVE

The objective of this study was to conduct a systematic and comprehensive review of qualitative research to examine the physical and psychological needs, as well as work experiences, of patients undergoing total knee replacement and total hip replacement surgeries during their process of returning to work.

METHODS

A systematic review and meta-synthesis of qualitative literature was conducted. A systematic search was conducted across 8 databases to identify qualitative or mixed-methods research on the needs and experiences of individuals with total knee replacement and total hip replacement who have returned to work. The search period extended from the inception of each database to March 2023. Two researchers independently utilized a predetermined search strategy to retrieve relevant English-language studies published in any year. The included studies were assessed for quality using the Critical Appraisal Skills Program appraisal tool. Findings from the studies were then summarized and integrated using the pooled integration method.

RESULTS

There were 10 studies in total. Three key themes were identified from the original research: needs during the return to work process and rehabilitation training, faith and support to return to work, and constraints and challenges at work.

CONCLUSION

Health care professionals and employers should conscientiously consider the physical and psychological requirements of patients who have undergone total knee replacement and total hip replacement when they are resuming work, taking into account the specific constraints and challenges that may arise in the workplace. To ensure a seamless transition back to work, it is essential to develop tailored occupational interventions, implement comprehensive return to work programs, and offer patients sufficient understanding and support.

IMPACT

The findings of this study offer valuable insights into the physical and psychological needs, as well as the work experiences, of patients who have undergone total knee replacement and total hip replacement during their reintegration into the workforce. These findings have the potential to assist health care professionals and employers in providing enhanced support to facilitate successful return-to-work outcomes for patients.

National survey of occupational advice for lower limb arthroplasty patients

BACKGROUND

Little is known what advice or support patients are given about return to work (RTW) after hip or knee replacement surgery.

AIMS

This study aims to understand the delivery, timing and content of 'RTW' advice currently delivered by surgical teams offering hip and knee replacements across the UK.

METHODS

National online survey exploring five specific areas relating to 'RTW' advice: (i) timings of interactions between hospital orthopaedic teams and patients prior to surgery, (ii) routine delivery of 'RTW' advice, (iii) methods used to deliver 'RTW' advice, (iv) confidence delivering advice and (v) need for an occupational 'RTW' advice intervention.

RESULTS

A total of 152 participants including surgeons, physiotherapists, occupational therapists and nurses from 59 different public and private health providers responded. Only 20% (n = 30) of respondents reported that working patients were identified as a specific subgroup in need of additional support. Overall, 62% (n = 92) stated that they did not routinely offer 'RTW' advice. When given, 'RTW' advice was almost always verbal, generic advice using blanket timescales and based on the respondent's anecdotal experience rather than the patients individualized needs. Overall, 116 (78%) felt an occupational advice intervention was needed.

CONCLUSIONS

This national survey demonstrated wide variation in the timing, content and delivery of information and advice for patients in work and intending to RTW after hip and knee replacement surgery. Current RTW advice provided to hip and knee replacement patients is inadequate.

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.

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.

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.

Return to work advice after total hip and knee replacement

BACKGROUND

Little is known about the information and advice on return to work received by patients undergoing total hip and knee replacement.

AIMS

To investigate patients' views and experiences of work-related advice provided by clinicians, and how this might be improved.

METHODS

Semi-structured interviews with patients who had undergone total hip and knee replacement, were working prior to surgery and intended to return to work. Data were analysed thematically.

RESULTS

Forty-five patients from three UK regions were consented. Eight themes were identified including lack of information, lack of an individualized approach and accessibility and acceptability of information dissemination methods. Patients identified their information needs and who they felt was best placed to address them.

CONCLUSIONS

Patients receive little information and advice on return to work following total hip and knee replacement, although not all patients required this. However, more focus is needed on providing this, and patients should be screened to ensure resources are best targeted with interventions being tailored to the individual.

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.

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.