Allied Health Clinicians' Uptake of Evidence in Stroke Rehabilitation: A Systematic Review of Determinants Targeted in Implementation Studies

OBJECTIVE

This study aimed to determine whether targeting specific implementation determinants is associated with allied health clinicians' uptake of evidence when implemented within stroke rehabilitation settings.

DATA SOURCES

7 key databases were searched to identify articles published between 1990 and 2022 for inclusion. Reference lists of relevant articles were hand searched.

STUDY SELECTION

Studies were independently screened by 2 authors and included if the implementation intervention targeted allied health clinical practice in any stroke rehabilitation context and reported at least 1 quantitative measure of evidence uptake. Thirty studies met inclusion criteria.

DATA EXTRACTION

Data were independently extracted by the first and second author. Implementation outcomes for each study were categorized as either mostly successful, partially successful, or not successful based on the degree of evidence uptake achieved. Determinants targeted were categorized using the Consolidated Framework for Implementation Research (CFIR).

DATA SYNTHESIS

Patterns between the degree of evidence uptake and determinants targeted across studies were analyzed by the first and second authors in 1 of 3 groups: A (pre-post statistical analysis), B (pre-post descriptive analysis), or C (post-only descriptive analysis). Patterns between evidence uptake and determinants targeted were first identified within groups A and B, with group C consulted to support findings. All studies categorized as "mostly successful" targeted facilitation in combination with establishing face-to-face networks and communication strategies. Conversely, no studies rated "not successful" targeted either of these determinants. Studies rated "partially successful" targeted either 1, but seldom both, of these determinants.

CONCLUSIONS

This review has provided descriptive evidence of determinants which may be important to target for allied health clinicians' uptake of evidence within stroke rehabilitation settings.

Comprehensive quality assessment for aphasia rehabilitation after stroke: protocol for a multicentre, mixed-methods study

INTRODUCTION

People with aphasia following stroke experience disproportionally poor outcomes, yet there is no comprehensive approach to measuring the quality of aphasia services. The Meaningful Evaluation of Aphasia SeRvicES (MEASuRES) minimum dataset was developed in partnership with people with lived experience of aphasia, clinicians and researchers to address this gap. It comprises sociodemographic characteristics, quality indicators, treatment descriptors and outcome measurement instruments. We present a protocol to pilot the MEASuRES minimum dataset in clinical practice, describe the factors that hinder or support implementation and determine meaningful thresholds of clinical change for core outcome measurement instruments.

METHODS AND ANALYSIS

This research aims to deliver a comprehensive quality assessment toolkit for poststroke aphasia services in four studies. A multicentre pilot study (study 1) will test the administration of the MEASuRES minimum dataset within five Australian health services. An embedded mixed-methods process evaluation (study 2) will evaluate the performance of the minimum dataset and explore its clinical applicability. A consensus study (study 3) will establish consumer-informed thresholds of meaningful change on core aphasia outcome constructs, which will then be used to establish minimal important change values for corresponding core outcome measurement instruments (study 4).

ETHICS AND DISSEMINATION

Studies 1 and 2 have been registered with the Australian and New Zealand Clinical Trial Registry (ACTRN12623001313628). Ethics approval has been obtained from the Royal Brisbane and Women's Hospital (HREC/2023/MNHB/95293) and The University of Queensland (2022/HE001946 and 2023/HE001175). Study findings will be disseminated through peer-reviewed publications, conference presentations and engagement with relevant stakeholders including healthcare providers, policy-makers, stroke and rehabilitation audit and clinical quality registry custodians, consumer support organisations, and individuals with aphasia and their families.

Health professionals' practices and perspectives of post-stroke coordinated discharge planning: a national survey

Background It is best practice for stroke services to coordinate discharge care plans with primary/community care providers to ensure continuity of care. This study aimed to describe health professionals' practices in stroke discharge planning within Australia and the factors influencing whether discharge planning is coordinated between hospital and primary/community care providers. Methods A mixed-methods survey informed by the Theoretical Domains Framework was distributed nationally to stroke health professionals regarding post-stroke discharge planning practices and factors influencing coordinated discharge planning (CDP). Data were analysed using descriptive statistics and content analysis. Results Data from 42 participants working in hospital-based services were analysed. Participants reported that post-stroke CDP did not consistently occur across care providers. Three themes relating to perceived CDP needs were identified: (1) a need to improve coordination between care providers, (2) service-specific management of the discharge process, and (3) addressing the needs of the stroke survivor and family . The main perceived barriers were the socio-political context and health professionals' beliefs about capabilities . The main perceived facilitators were health professionals' social/professional role and identity, knowledge, and intentions . The organisation domain was perceived as both a barrier and facilitator to CDP. Conclusion Australian health professionals working in hospital-based services believe that CDP promotes optimal outcomes for stroke survivors, but experience implementation challenges. Efforts made by organisations to ensure workplace culture and resources support the CDP process through policies and procedures may improve practice. Tailored implementation strategies need to be designed and tested to address identified barriers.

Pilot trial of the online implementation intervention Aphasia Nexus: Connecting Evidence to Practice

PURPOSE

Aphasia Nexus: Connecting Evidence to Practice is a theoretically-based online implementation intervention designed to overcome the barriers related to the implementation of intensive and comprehensive aphasia services. The objective was to establish the feasibility of incorporating Aphasia Nexus within routine clinical practice through an evaluation of: (1) its potential to positively influence the intensity and/or comprehensiveness of aphasia services; (2) the ability of selected outcome measures to capture changes to factors influencing implementation; and (3) the acceptability of the website to on-site speech-language pathologists (SLPs).

METHOD

A single arm pre-post pilot trial was conducted within an Australian health service. The design collected qualitative and quantitative pre-post data in the form of therapy logs, behaviour change questionnaires, and a post-intervention focus group. Data were collected one week prior to, and one week following, a 12 week implementation period where participating SLPs (n = 5) were provided access to the Aphasia Nexus website.

RESULT

Quantitative data revealed improvements in the median time per patient with aphasia from 65 to 115 minutes per week (intensity/dose), an additional 50 minutes per week. SLPs trialled at least one new therapy approach (Attentive Reading and Constrained Summarisation) and service delivery model (group therapy) representing an increase in the comprehensiveness of their services to patients. SLPs perceived a reduction in the barriers associated with the promotion of new aphasia services. Qualitative analysis of focus group discussion revealed that participants considered Aphasia Nexus in the overarching theme of practice efficiency (obtaining the best outcome from the least amount of effort) and the sub-themes of accessible therapy resources and the prioritisation of time.

CONCLUSION

Overall, Aphasia Nexus was considered a useful clinical tool with the potential to positively influence clinical aphasia practice. These results will inform further implementation intervention refinements and will inform the methodology of future research.

An updated systematic review of stroke clinical practice guidelines to inform aphasia management

BACKGROUND

Aphasia is a common consequence of stroke, and people who live with this condition experience poor outcomes. Adherence to clinical practice guidelines can promote high-quality service delivery and optimize patient outcomes. However, there are currently no high-quality guidelines specific to post-stroke aphasia management.

AIMS

To identify and evaluate recommendations from high-quality stroke guidelines that can inform aphasia management.

SUMMARY OF REVIEW

We conducted an updated systematic review in accordance with PRISMA guidelines to identify high-quality clinical guidelines published between January 2015 and October 2022. Primary searches were performed using electronic databases: PubMed, EMBASE, CINAHL, and Web of Science. Gray literature searches were conducted using Google Scholar, guideline databases, and stroke websites. Clinical practice guidelines were evaluated using the Appraisal of Guidelines and Research and Evaluation (AGREE II) tool. Recommendations were extracted from high-quality guidelines (scored > 66.7% on Domain 3: "Rigor of Development"), classified as aphasia-specific or aphasia-related, and categorized into clinical practice areas. Evidence ratings and source citations were assessed, and similar recommendations were grouped. Twenty-three stroke clinical practice guidelines were identified and 9 (39%) met our criteria for rigor of development. From these guidelines, 82 recommendations for aphasia management were extracted: 31 were aphasia-specific, 51 aphasia-related, 67 evidence-based, and 15 consensus-based.

CONCLUSION

More than half of stroke clinical practice guidelines identified did not meet our criteria for rigorous development. We identified 9 high-quality guidelines and 82 recommendations to inform aphasia management. Most recommendations were aphasia-related; aphasia-specific recommendation gaps were identified in three clinical practice areas: "accessing community supports," "return to work, leisure, driving," and "interprofessional practice."

Exploring impairments and allied health professional utilisation in people with myasthenia gravis: A cross-sectional study

This study aimed to explore how people with myasthenia gravis experience impairments in vision, dizziness, hearing, and fatigue, and how these relate to balance confidence, community participation, and health-related quality of life. Additionally, this study investigated the utilisation and perception of the allied health role in managing these impairments in the Australian context. Visual and hearing impairments, along with fatigue, were found to be correlated with health-related quality of life and community participation to varying degrees, while visual impairment and dizziness were correlated with balance confidence. Perception and utilisation of allied health professionals was variable; common barriers to better utilisation included participant perception of clinicians having poor knowledge around myasthenia gravis, previous poor experiences with clinicians, uncertainty about the clinicians' role, and lack of awareness that symptoms were associated with myasthenia gravis. Further research exploring clinicians' knowledge of myasthenia gravis is recommended, along with education for people with the disease about symptoms associated and how to appropriately access care.

A survey of speech pathologists' opinions about the prospective acceptability of an online implementation platform for aphasia services

BACKGROUND

Online knowledge translation (KT) approaches are becoming increasingly prevalent within healthcare due to their accessibility and facilitation of international support networks. Online platforms enable timely and far-reaching dissemination of current evidence and best-practice recommendations. Although there is potential to improve the uptake of rehabilitation guidelines, it is essential to consider the acceptability of online approaches to healthcare professionals to ensure their successful integration within everyday clinical settings.

AIMS

To establish the prospective acceptability of a theoretically informed online intervention for speech pathologists, Aphasia Nexus: Connecting Evidence to Practice, that aims to facilitate the implementation of aphasia best practice.

METHODS & PROCEDURES

A mixed-methods multinational electronic survey based on the Theoretical Framework of Acceptability (TFA) completed by aphasia researchers and clinicians.

OUTCOMES & RESULTS

A total of 43 participants completed the survey with 91% (n = 39) indicating that they would use Aphasia Nexus. Understanding the intervention and how it works (intervention coherence as per the TFA) was the key factor influencing the likelihood of integration within everyday clinical practice. Participants identified potential areas where the intervention could influence service change and also recommended further design and content changes to improve the intervention.

CONCLUSIONS & IMPLICATIONS

Aphasia Nexus is an acceptable platform for further feasibility testing in the form of a pilot trial within an Australian-based health service. The study progresses the theory of TFA as it was a valuable framework facilitating the identification of prominent factors influencing acceptability. The study also informs further intervention refinements in preparation for the next stage of research.

WHAT THIS PAPER ADDS

What is already known on the subject Online strategies have the potential to enhance KT and promote the uptake of rehabilitation guidelines. An online intervention, however, can only be effective if implemented well. For this reason, it is essential to establish the acceptability of online interventions to the intended recipients and therefore increase the likelihood of successful implementation. What this paper adds to existing knowledge This study used a theoretically based framework to establish the acceptability of an online implementation intervention, Aphasia Nexus, to multinational aphasia clinicians and researchers. It demonstrated the value in identifying the prominent factors influencing acceptability to inform further intervention refinements and warrant continuing research. What are the potential or actual clinical implications of this work? Speech pathologists should use online platforms to drive the implementation of best practice on an international scale. It is important for clinicians to have an in-depth understanding of online interventions and how they work to enhance their successful uptake into routine clinical practice. Aphasia Nexus is an acceptable online platform for implementing best practice in aphasia.

Communication partner training with familiar partners of people with aphasia: A systematic review and synthesis of barriers and facilitators to implementation

BACKGROUND

Factors influencing the implementation of communication partner training (CPT) with familiar partners of people with aphasia (PWA) have previously been documented using disparate approaches. To date there has been no synthesis of these factors using a common theoretical framework. Investigating CPT implementation factors using a common theoretical framework may further our understanding of universal barriers and guide future development of tailored, theoretically informed implementation strategies.

AIMS

(1) To determine the perceived and/or observed barriers and facilitators to implementing CPT with familiar partners of adults with aphasia; (2) to map extracted barriers and facilitators to a common theoretical framework; (3) to synthesize extracted barriers and facilitators; and (4) to identify potential implementation strategies to address the most frequently identified barriers and facilitators.

METHODS & PROCEDURES

A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Four electronic databases (MEDLINE, EMBASE, CINAHL, Web of Science) were systematically searched in April 2021. Empirical qualitative and/or quantitative research studies reporting barriers/facilitators to speech-language therapists (SLTs) implementing CPT with familiar partners of adults with aphasia were included. The search was limited to English or French articles with no date limit applied. Methodological quality of included studies was assessed using the Mixed-Methods Appraisal Tool (MMAT). A framework and content analysis was then conducted to extract and synthesize the implementation factors in alignment with the Theoretical Domains Framework (TDF), followed by a theoretically informed mapping exercise to identify potential implementation strategies.

RESULTS & MAIN CONTRIBUTION

The database searches yielded 2115 studies. Following screening, 17 studies were included in the review. Overall, the included studies had good methodological quality. Extracted implementation factors were classified as barriers, facilitators or mixed (i.e., both) and aligned with 13 of the 14 TDF domains, plus two additional domains: 'carer perspectives on the CPT intervention' and 'patient/carer characteristics'. Synthesized data revealed eight key theoretical domains: Environmental context and resources; Social influences; Beliefs about consequences; Skills; Memory, attention and decision-making; Knowledge; Beliefs about capabilities; and Reinforcement. Within each domain, the research team identified common categories and developed illustrative examples of theoretically informed implementation strategies.

CONCLUSIONS & IMPLICATIONS

This systematic review and theory-informed synthesis of previously reported CPT implementation factors enabled the identification of key barriers to SLTs delivering this best practice. This led to proposed implementation strategies that should be validated, refined and evaluated in future research involving stakeholders who have contextual understanding of implementing CPT.

WHAT THIS PAPER ADDS

What is already known on the subject CPT of familiar partners of PWA is an effective intervention that is inconsistently used in clinical settings. Factors influencing CPT implementation have previously been identified, but using disparate approaches and frameworks. A synthesis of these factors articulated around a common framework is currently not available. What this paper adds to existing knowledge This paper provides a theory-informed synthesis of previously reported barriers and facilitators to SLTs implementing CPT with familiar partners of PWA. It highlights key factors influencing the uptake of this best practice and includes suggestion of implementation strategies to address them. What are the potential or actual clinical implications of this work? The key influencing factors and proposed implementation strategies reported in this paper may support stakeholders in the future design of tailored and theoretically informed implementation strategies aiming to improve the delivery of familiar CPT in their setting.

Fragmented care and missed opportunities: the experiences of adults with myasthenia gravis in accessing and receiving allied health care in Australia

PURPOSE

Although allied health services are important adjuncts to medical care for people with myasthenia gravis (MG), the underutilisation of these services is not well understood within the Australian context. It is critical to explore patients' perceptions to develop services that meet consumer needs. This study, therefore, sought to obtain insight into MG patients' perspectives and experiences, in addition to the outcomes, of accessing allied health services.

MATERIALS AND METHODS

Thirteen Australian adults with MG participated in semi-structured interviews. Qualitative analysis was conducted inductively using thematic content analysis.

RESULTS

Four themes were identified: (1) missed opportunities and unmet care needs were common, due to frequent patient-provider communication breakdowns and a lack of referral protocols, (2) personal factors - patient self-advocacy influenced their perceived need, with some lacking confidence to seek help, (3) perceived benefit and health provider capacities - most valued allied health despite differing perceptions of health professionals' attitudes, skills, and willingness to learn, and (4) a resultant fragmentation of care between services was universal.

CONCLUSIONS

Findings highlighted a need for clear referral pathways, coordinated multidisciplinary care, improved access to community-based services and education for allied health professionals about MG.Implications for rehabilitationAdults with myasthenia gravis (MG) report a lack of referral pathways to allied health services, leading to unmet needs and fragmented care.Although there is a perceived benefit to allied health care, experiences are impacted by health provider capacity and attitudes.There needs to be an overall shift towards multidisciplinary care for people with MG, and the development of clear referral pathways.Specific education about MG should be available for allied health professionals to improve their knowledge and skills in treating this population.

Do people with Myasthenia Gravis need speech-language pathology services? A national survey of consumers' experiences and perspectives

Purpose: This study explored experiences of bulbar (speech, voice and swallowing) symptoms in Australian adults with Myasthenia Gravis (MG), and the relationship between these symptoms and community participation and quality-of-life. Further, it examined access to and experiences with speech-language pathology (SLP) services, and awareness and perceptions of the SLP's role.Method: A cross-sectional mixed methods online survey collected data using researcher-designed questions and patient-reported outcome measures (PROMs) including the Dysarthria Impact Profile (DIP), Voice Handicap Index (VHI), Dysphagia Handicap Index (DHI), Community Integration Questionnaire-Revised (CIQ-R), and Myasthenia Gravis Quality of Life-Revised 15 (MG-QOL15r). Analyses included descriptive and non-parametric statistics, and content analysis.Result: Participants were 111 adults with MG living in Australia. 74% of respondents reported experiencing symptoms of speech difficulties but only 20% of those were referred to SLP services. Similarly, 85% of respondents reported experiencing swallowing difficulties, but only 26% were referred to SLP. Voice handicap (VHI) was strongly correlated with the psychosocial impact of dysarthria (DIP) and dysphagia handicap (DHI). Increased voice and dysphagia handicap were moderately correlated with worse quality-of-life. There was generally poor awareness of the SLP's role and many were reluctant to attend SLP appointments.Conclusion: These findings highlight unmet consumer needs for MG-related bulbar symptoms, and a lack of awareness of SLP services. It is suggested that, in addition to other strategies, consumer education and increased awareness are required to address these unmet needs.

Sustaining acute speech-language therapists' implementation of recommended aphasia practices: A mixed methods follow-up evaluation of a cluster RCT

BACKGROUND

While implementation studies in aphasia management have shown promising improvements to clinical practice, it is currently unknown if aphasia implementation outcomes are sustained and what factors may influence clinical sustainability.

AIMS

To evaluate the sustainment (i.e., sustained improvement of aphasia management practices and domains influencing clinicians' practice) and sustainability (i.e., factors influencing sustainability) outcomes of the Acute Aphasia IMplementation Study (AAIMS).

METHODS & PROCEDURES

A convergent interactive mixed-methods sustainability evaluation was conducted on two previously delivered implementation interventions (AAIMS). The AAIMS interventions were targeted at improving either written aphasia-friendly information provision (Intervention A) or collaborative goal-setting (Intervention B). Outcomes were collected 2 and 3 years post-implementation, addressing the research questions of sustainment (e.g., medical record audits and behavioural constructs questionnaires) and sustainability (e.g., post-study focus groups and organizational readiness surveys). Quantitative sustainability data were compared with post-implementation data, allowing for sustainment to be determined. Clinicians' perspectives on sustainability outcomes and challenges were analysed using framework analysis and integrated with the quantitative findings.

OUTCOMES & RESULTS

A total of 35 speech-language therapists (SLTs) from four hospitals participated. The medical records of 79 patients were audited in the sustainability period compared with the 107 medical records audited during AAIMS. Overall, there was variable sustainment of the target behaviours; implementation for Intervention A was not sustained at either sustainability time point (2018 = 47.8% decrease; 2019 = 22.78% decrease), but implementation for Intervention B was sustained at both time points (2018 = 7.78% increase; 2019 = 18.1% increase). There was a pattern of sustained change in the behaviour change domains targeted by the implementation interventions, where scores of the targeted domains increased over time (0.13, 95% confidence interval (CI) = -0.05 to 0.30) and scores of the non-targeted domains declined (-0.03, 95% CI = -0.11 to 0.04). Factors influencing sustainability were mainly related to 'processes', 'the inner context' and 'SLT characteristics', and these interacted dynamically to account for variation between teams.

CONCLUSIONS & IMPLICATIONS

Implementation outcomes (i.e., practice changes) were not sustained to the same level for three of the four participating SLT teams, with variable or partial sustainment most common. While the factors influencing sustainability differed depending on the context and individuals involved, the most important factor influencing outcomes seemed to be the level to which behaviour-change processes and strategies were embedded within the SLT department. Future implementation studies should incorporate sustainability measures from the onset and include follow-ups and monitoring systems to help support sustained change in the long term.

WHAT THIS PAPER ADDS

What is already known on the subject In post-stroke aphasia management, there are few examples of long-term sustainability of implementation outcomes. It is therefore unknown what factors are potentially important to sustain implementation of best-practice recommendations in aphasia services. What this paper adds to existing knowledge There is potential for implementation outcomes to be sustained long term, but sustainment is impacted by a range of factors. Ongoing facilitation or follow-up after initial implementation may to useful to promote sustainment, but is not essential if processes are sufficiently embedded. Gradual implementation into practice may lead to better sustainment than rapid change that is quickly forgotten. What are the potential or actual clinical implications of this work? Future implementation efforts should incorporate sustainability measures from the onset. Applying a sustainability framework was useful to guide evaluations and explore factors influencing the sustainment outcomes and is recommended for those interested in sustainability. Results from our evaluation can be used to guide refinement and support future development of sustainable implementation interventions.

Core Outcome Set Use in Poststroke Aphasia Treatment Research: Examining Barriers and Facilitators to Implementation Using the Theoretical Domains Framework

Purpose A core outcome set (COS; an agreed minimum set of outcomes) was developed to address the heterogeneous measurement of outcomes in poststroke aphasia treatment research. Successful implementation of a COS requires change in individual and collective research behavior. We used the Theoretical Domains Framework (TDF) to understand the factors influencing researchers' use and nonuse of the Research Outcome Measurement in Aphasia (ROMA) COS. Method Aphasia trialists and highly published treatment researchers were identified from the Cochrane review of speech and language therapy for aphasia following stroke and through database searches. Participants completed a theory-informed online survey that explored factors influencing COS use. Data were analyzed using descriptive statistics and qualitative content analysis. Results Sixty-four aphasia researchers from 13 countries participated. Most participants (81%) were aware of the ROMA COS, and participants identified more facilitators than barriers to its use. The TDF domain with the highest agreement (i.e., facilitator) was "knowledge" (84% agree/strongly agree). Participants had knowledge of the measures included in the ROMA COS, their associated benefits, and the existing recommendations. The TDF domains with the least agreement (i.e., barriers) were "reinforcement" (34% agree/strongly agree); "social influences" (41% agree/strongly agree); "memory, attention, and decision processes" (45% agree/strongly agree); and "behavioral regulation" (49% agree/strongly agree). Hence, participants identified a lack of external incentives, collegial encouragement, and monitoring systems as barriers to using the ROMA COS. The suitability and availability of individual measurement instruments, as well as burden associated with collecting the COS, were also identified as reasons for nonuse. Conclusions Overall, participants were aware of the benefits of using the ROMA COS and believed that its implementation would improve research quality; however, incentives for routine implementation were reported to be lacking. Findings will guide future revisions of the ROMA COS and the development of theoretically informed implementation strategies. Supplemental Material https://doi.org/10.23641/asha.16528524.

Setting a prioritized agenda to drive speech-language therapy research in health

BACKGROUND

Prioritized research agendas are viewed internationally as an important method for ensuring that health research meets actual areas of clinical need. There is growing evidence for speech-language therapy-prioritized research agendas, particularly in disorder-specific areas. However, there are few general research priority agendas to guide speech-language therapy research.

AIMS

To collaboratively develop a prioritized research agenda for an Australian public health context with clinical speech-language therapists (SLTs), academic SLTs and consumers of speech-language therapy services.

METHODS & PROCEDURES

An initial stimulus list of potential research areas for prioritization was collected from SLTs via an online survey. Two categories (service delivery and expanded scope of practice) were selected from this list for prioritization due to their relevance across multiple health services. The Nominal Group Technique (NGT) was used to develop a prioritized research agenda for each of the two categories. One NGT session was conducted with each of the three participant groups (clinical SLTs, academic SLTs, consumers) for each category (total NGT sessions = six). The prioritization data for each group within each category were summed to give a single, ranked prioritized research agenda for each category.

OUTCOMES & RESULTS

Two prioritized research agendas were developed. Within each agenda, SLTs and consumers prioritized a need for more research in areas related to specific practice areas (e.g., Alternative and Augmentative Communication, Communication Partner Training), as well as broader professional issues (e.g., telehealth, working with culturally and linguistically diverse families).

CONCLUSIONS & IMPLICATIONS

The current findings support the need for funding proposals and targeted projects that address these identified areas of need.

WHAT THIS PAPER ADDS

What is already known on this subject Evidence-based practice is a critical component of SLT practice. There is often a disconnect between the research evidence generated and areas of clinical need, and in some areas a lack of evidence. Prioritized research agendas can help drive research in areas of clinical need. What this paper adds to existing knowledge A collaborative, prioritized SLT research agenda was developed using the NGT according to the views of clinical SLTs, academic SLTs and consumers of speech-language therapy services in a conglomerate of public health services. SLTs and consumers identified a need for further research in specific areas of SLT practice as well as broader emerging professional issues What are the potential or actual clinical implications of this work? Targeted research projects funded on a large scale are required to address these identified areas of need. Other health services around the world could replicate this prioritization process to drive research in areas of clinical need.

Prioritizing guideline recommendations for implementation: a systematic, consumer-inclusive process with a case study using the Australian Clinical Guidelines for Stroke Management

BACKGROUND

Implementation of evidence-based care remains a key challenge in clinical practice. Determining "what" to implement can guide implementation efforts. This paper describes a process developed to identify priority recommendations from clinical guidelines for implementation, incorporating the perspectives of both consumers and health professionals. A case study is presented where the process was used to prioritize recommendations for implementation from the Australian Stroke Clinical Guidelines.

METHODS

The process was developed by a multidisciplinary group of researchers following consultation with experts in the field of implementation and stroke care in Australia. Use of the process incorporated surveys and facilitated workshops. Survey data were analysed descriptively; responses to ranking exercises were analysed via a graph theory-based voting system.

RESULTS

The four-step process to identify high-priority recommendations for implementation comprised the following: (1) identifying key implementation criteria, which included (a) reliability of the evidence underpinning the recommendation, (b) capacity to measure change in practice, (c) a recommendation-practice gap, (d) clinical importance and (e) feasibility of making the recommended changes; (2) shortlisting recommendations; (3) ranking shortlisted recommendations and (4) reaching consensus on top priorities. The process was applied to the Australian Stroke Clinical Guidelines between February 2019 and February 2020. Seventy-five health professionals and 16 consumers participated. Use of the process was feasible. Three recommendations were identified as priorities for implementation from over 400 recommendations.

CONCLUSION

It is possible to implement a robust process which involves consumers, clinicians and researchers to systematically prioritize guideline recommendations for implementation. The process is generalizable and could be applied in clinical areas other than stroke and in different geographical regions to identify implementation priorities. The identification of three clear priority recommendations for implementation from the Australian Stroke Clinical Guidelines will directly inform the development and delivery of national implementation strategies.

Development of an online implementation intervention for aphasia clinicians to increase the intensity and comprehensiveness of their service

PURPOSE

To describe the process and outcome of a user and theory informed online intervention for speech pathologists targeting the implementation of intensive and comprehensive aphasia services.

METHODS

The design process followed the eight steps outlined by the Behaviour Change Wheel and incorporated the principles of Integrated Knowledge Translation (IKT). Eight speech pathology researchers and clinicians from four countries (Australia, Canada, the United Kingdom and Ireland) contributed to three focus groups via videoconference.

RESULTS

The online platform, Aphasia Nexus: Connecting Evidence to Practice, provides resources, guidance and support for speech pathologists seeking to improve the intensity and comprehensiveness of their aphasia service. A collaborative and iterative design process facilitated the creation of an intervention envisioned by participants.

CONCLUSIONS

The website contains both interactive elements and resource links which have been arranged under the three headings of resources, action and support. The inclusion of multi-national researchers and clinicians benefitted a design process to make implementation more likely.IMPLICATIONS FOR REHABILITATIONTheoretically informed implementation interventions aim to change the everyday clinical practice of health workers.An online platform has been developed to support speech pathologists' implementation of intensive and comprehensive aphasia services.A collaborative design process can be beneficial in creating an intervention that is relevant to research-users and is more likely to be implemented.

Delivering an iterative Communication Partner Training programme to multidisciplinary healthcare professionals: A pilot implementation study and process evaluation

BACKGROUND

Despite evidence that Communication Partner Training (CPT) can enable health professionals to communicate more effectively with people with aphasia (PWA), an evidence-practice gap exists. To address this, a tailored implementation intervention was developed and trialled to improve health professionals' implementation of communication strategies in a subacute setting.

AIMS

To explore the outcomes and perceived feasibility, acceptability and potential effectiveness of an iterative CPT implementation intervention on multidisciplinary healthcare professionals' communication with PWA.

METHODS & PROCEDURES

The CPT implementation intervention was delivered to two groups of healthcare professionals (n = 6 and 7) approximately 6 months apart. The intervention underwent two iterations targeting emerging barriers to implementation success, with Group 2 receiving a modified version of the Group 1 intervention. A concurrent qualitative process evaluation was conducted to understand key factors determining implementation outcomes. Quantitative outcomes were recorded at baseline and 3-month follow-up, including the Measure of Skill in Supported Communication (MSC), a customized behavioural determinants survey mapped to the Theoretical Domains Framework (TDF) and the Organizational Readiness for Change survey. Focus groups and semi-structured interviews were conducted with health professional participants and the speech-language therapist trainer to explore perceptions of feasibility, acceptability and potential effectiveness. Content analysis was used to analyse the qualitative data, with categories and themes generated.

OUTCOMES & RESULTS

The Group 2 implementation intervention was adapted based on feedback and reflections from Group 1 participants to incorporate more time for practice interactions and discussion during training, individual follow-up sessions and provision of accessible resources to aid communication attempts. There were greater improvements seen in the Group 2 outcomes on both the MSC and the TDF survey, suggesting that the iterative tailoring of the intervention was successful in addressing the barriers to change and led to improved implementation. The difference between the group's outcomes may also partly be explained by the impact of organizational readiness, which decreased during Group 1's implementation period. Despite similar themes emerging from the stakeholder perspectives in both groups (training factors, implementation facilitators, implementation barriers, and changes in knowledge and practice), these diverted in ways which served to explain the different implementation outcomes.

CONCLUSIONS & IMPLICATIONS

An iteratively adapted CPT implementation intervention targeting healthcare professionals' use of supported communication strategies was feasible and acceptable for most participants. The implementation intervention was potentially effective in changing participants' communication with PWA, particularly for Group 2. Future CPT implementation efforts should continue to incorporate stakeholder input and tailor strategies to the organizational context, and measure whether outcomes are sustained in the long term. What this paper adds What is already known on the subject CPT is a complex intervention that can improve communication access and outcomes for PWA. However, there are barriers to both delivering CPT programmes to staff, and for staff in modifying their communication behaviours. Despite increasing efforts to improve CPT implementation, it remains largely unclear whether CPT implementation interventions are effective in improving interactions between staff and patients, and what elements of an implementation intervention result in changed behaviour. What this study adds to existing knowledge This study showed that adopting an iterative, barriers-focused approach to implementation facilitated practice change for one of the groups that participated in the programme. Incorporating stakeholder feedback in an ongoing way led to improvements in feasibility, acceptability and potential effectiveness, with several of the main barriers being effectively addressed by the intervention. Some key mechanisms of change were identified. What are the potential or actual clinical implications of this work It is necessary to develop active, targeted implementation strategies to support healthcare professionals to modify their communication, monitor implementation barriers as they arise and modify behaviour-change strategies accordingly. In a similar context, it is suggested that CPT implementation interventions should incorporate the use of audit feedback, physical resources and educational lectures paired with interactions with PWA in order to bring about change, with ongoing support and facilitation.

Implementation of an integrated multidisciplinary Movement Disorders Clinic: applying a knowledge translation framework to improve multidisciplinary care

PURPOSE

To evaluate the implementation of an integrated multidisciplinary Movement Disorder Clinic using a model of knowledge translation.

METHODS

A mixed methods design was used to evaluate implementation outcomes. After recognising poor referral rates to allied health, Movement Disorder Clinic team-members identified implementation barriers. Team- and process-level implementation strategies were designed and tailored to address these barriers. The primary outcome measure was the change in the proportion of patients referred to allied health, determined by comparing pre- and post-implementation documentation audits. Secondary outcome measures included clinician and consumer surveys to identify ongoing implementation barriers and stakeholder satisfaction.

RESULTS

Documentation from 90 medical records was included in the audits (post-intervention n = 45). There was a significant improvement in the referral rates to allied health from 53% to 84% (mean improvement 31%, p = 0.003, Fisher's exact test). However, documentation of disease education decreased by 38% (p = 0.000, Fisher's exact test). Movement Disorder Clinic team-members identified three main barriers to ongoing implementation: "memory and automaticity", "environmental context and resources" and "beliefs about capabilities". Thirty-seven consumer surveys were completed, showing high levels of satisfaction (86%) but ongoing educational needs (51%).

CONCLUSIONS

Implementation of an integrated multidisciplinary Movement Disorder Clinic was facilitated by a knowledge translation framework, leading to improved allied health referral rates and high levels of staff and consumer satisfaction, but unmet educational needs of consumers. Future research in the field of multidisciplinary healthcare for people with movement disorders is needed to determine the impact of these changes on patients' healthcare outcomes.Implications for rehabilitationMultidisciplinary integrated healthcare models may lead to better outcomes in progressive diseases such as Parkinson's disease, however, can be challenging to implement.A knowledge translation framework facilitated successful implementation of an integrated multidisciplinary Movement Disorders Clinic, leading to significantly improved rates of appropriate referrals to allied health, and staff and consumer satisfaction.Team-members identified three main barriers to ongoing implementation - "memory and automaticity", "environmental context and resources," and "beliefs about capabilities" - which may impact sustainability and should be considered in future implementation efforts.

The Acute Aphasia IMplementation Study (AAIMS): a pilot cluster randomized controlled trial

BACKGROUND

Effective implementation strategies to improve speech and language therapists' (SLTs) aphasia management practices are needed. Australian SLTs working in the acute setting have reported inconsistent implementation of post-stroke aphasia guideline recommendations. Therefore, implementation efforts to address these gaps are necessary. However, little is known about the effectiveness of behaviour-change strategies in SLTs providing acute aphasia management.

AIMS

This study designed and tested the feasibility, acceptability and potential effectiveness of a tailored implementation strategy to improve acute SLTs' uptake of evidence in two areas of practice: aphasia-friendly information provision; and collaborative goal setting.

METHODS & PROCEDURES

A pilot cluster randomized controlled trial design was used (retrospective trial registration number ACTRN12618000170224). Four acute SLT teams were randomly assigned to receive either Intervention A (targeted at improving information provision) or Intervention B (targeted at improving collaborative goal setting), and were blinded to their allocation. Interventions were tailored to address known barriers and included a face-to-face workshop incorporating behaviour-change techniques. Outcomes addressed the research questions of feasibility (e.g., treatment fidelity and retention of participants), acceptability (e.g., post-study focus groups) and potential effectiveness (e.g., medical record audits and behaviour construct surveys). The quantitative data were recorded at baseline and 3-6-month follow-up, allowing for change scores to be calculated.

OUTCOMES & RESULTS

All four clusters completed the study, with 37 SLTs participating. The majority of participants were female (36/37 = 97.3%), entry-level clinicians (15/37 = 40.5%), with a mean age of 30 years. Medical record data from 107 patients were included (post-intervention n = 61; information provision intervention n = 36, goal-setting intervention n = 25). Overall, there was a significant improvement in the target behaviour for Intervention A (mean improvement 52.78%, p = 0.001), but a small non-significant change in the target behaviour for Intervention B (8.46%, p = 0.406). There were potentially significant changes seen in several, but not all, of the domains targeted by the interventions (e.g., Knowledge (p = 0.014), Beliefs about Capabilities (p = 0.032), and Environmental Context and Resources (p = 0.000) for Intervention A).

CONCLUSIONS & IMPLICATIONS

This study showed that a tailored implementation intervention targeting acute SLTs' aphasia management practices was feasible to deliver and acceptable for most participants. In addition, the interventions were potentially effective, particularly for the information provision behaviour targeted by Intervention A. It was possible partially to explain the mechanisms of behaviour change that occurred during the study.

Neuroscientific Implications in Assessment and Intervention for Aphasia

Within an overarching theme of generational change in aphasiology, the aims of this paper are to (a) unify the neuroscience of the language impairment of aphasia with the psychosocial science of aphasia, (b) consider the implications of technology and (c) address the global challenge of translational research in this field. To achieve the first two aims, 10 principles of neuroplasticity will be interpreted within the World Health Organization's International Classification of Functioning, Disability and Health (ICF). Two novel treatment approaches to aphasia (UQ Aphasia LIFT and CommFit™) will be described that illustrate how the neuroplasticity principles can be interpreted more broadly within the ICF. The global challenge of translational research will bring the perspective of clinicians and consumers through to aphasia research via 3 recent sets of best practice statements for aphasia. Each demonstrates how the field of aphasiology is undertaking a knowledge synthesis within its broader remit of knowledge transfer and exchange. The Australian Aphasia Rehabilitation Pathway is described as a way of creating living clinical guidelines that are helpful to all stakeholders in aphasia research.