Holmes, Jane A.
(2018)
Implementing complex rehabilitation interventions in research: the example of vocational rehabilitation for people with traumatic brain injury.
PhD thesis, University of Nottingham.
Abstract
Background: Research does not always translate into improved patient outcomes because of difficulties implementing complex health interventions. Distinguishing between effectiveness and factors affecting implementation is critical to improving trials of rehabilitation interventions. Understanding barriers and facilitators encountered when delivering complex interventions, such as rehabilitation, in the research environment requires examination. Implementation research is the study of methods to promote the uptake of research findings into routine practice and can help identify and explain barriers and facilitators. The aim of this project was to understand factors that affect the delivery of complex rehabilitation interventions in research, focussing on vocational rehabilitation for people with traumatic brain injury.
Methods: Exploratory mixed methods were used to understand factors (barriers and facilitators) affecting the implementation of rehabilitation interventions delivered in research for people with long term neurological conditions including traumatic brain injury. In study 1, a systematic review investigated barriers and facilitators to the implementation of complex rehabilitation interventions delivered in clinical trials and other research. The review method involved developing search terms and searches included 11 databases, trial registries and author citations. All research methodologies were included. After screening titles and abstracts, two reviewers independently shortlisted studies. A third resolved discrepancies. Studies were appraised using the Mixed Methods Appraisal Tool. One reviewer extracted data in two stages; 1) descriptive study data, 2) units of text describing barriers and facilitators to implementation. Data were synthesised by; 1) mapping determinants to the Conceptual Framework for Implementation Fidelity and the Consolidated Framework for Implementation Research; 2) thematic analysis.
Study 2 describes the development of a training package, used as an implementation strategy, to train NHS occupational therapists to deliver Early Specialist Traumatic brain injury Vocational Rehabilitation in three English NHS sites in the context of a rehabilitation trial. The training package was developed by "experts" in vocational rehabilitation and traumatic brain injury. It included a manual, direct instruction and mentoring. The confidence of the occupational therapists to deliver the intervention to trial participants with traumatic brain injury was measured before and after training and its usefulness examined via mentoring records and through early and late interviews with the trained occupational therapists. Implementation issues were mapped to the Consolidated Framework for Implementation Research and Comprehensive Framework for Implementation Fidelity.
In Study 3 the extent to which the intervention was delivered as intended was investigated. A content form and fidelity checklist were developed. Fidelity was measured using these tools and triangulated with clinical and mentoring records. Barriers and facilitators were explored in interviews with the occupational therapists, trial participants, their employers and NHS staff in each site and triangulated with clinical and mentoring records and mapped to CFIR and CFIF.
Results: Study 1 found it was possible to identify factors affecting the implementation of complex interventions in rehabilitation trials, even when researchers had not set out to report these. Treatment adherence, its acceptability and causes of attrition were the most frequently reported barriers and facilitators. The quality of intervention delivery, the preparedness of organisations to implement an intervention as part of a trial and the developmental readiness or ‘trialability’ of interventions were rarely reported. The findings from this study highlighted the potential barriers that trial occupational therapists might encounter when delivering Early Specialist Traumatic brain injury Vocational Rehabilitation.
Study 2 found that experienced occupational therapists can be trained to deliver a complex intervention in a rehabilitation trial. Barriers and facilitators identified individual and organisational level barriers and facilitators. Soon after being trained, occupational therapists identified that direct instruction and the training manual were important in helping them implement the intervention. However, later they indicated that the manual was not used. Mentoring was identified as the most useful element of the training package in both early and late interviews.
Study 3 found that occupational therapists delivered Early Specialist Traumatic brain injury Vocational Rehabilitation with fidelity. Factors facilitating implementation fidelity included expert mentoring, community rehabilitation experience and an intervention that could be tailored to individual need. Barriers included lack of access to NHS systems, backfill and support from NHS managers. The following factors both helped and hindered; communication with participants, acceptability of the intervention, individual and changing needs of study participants and interagency working.
Conclusion: Using implementation research frameworks, such as Consolidated Framework for Implementation Research and Conceptual Framework for Implementation Fidelity, to identify, measure and describe barriers and facilitators can elicit important information to assist researchers in improving rehabilitation trial design, ensuring more robust trial outcomes, reduce the risk of type III errors and expedite translation of research into improved patient outcomes. Expert mentoring was considered essential to ensuring implementation fidelity, alongside case discussions and direct instruction about research contamination issues. Implementation of complex rehabilitation interventions, such as Early Specialist Traumatic brain injury Vocational Rehabilitation, is affected by a number of factors acting as barriers and or facilitators at the individual and organisational level.
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