Research Article: Implementing a function-based cognitive strategy intervention within inter-professional stroke rehabilitation teams: Changes in provider knowledge, self-efficacy and practice

Date Published: March 11, 2019

Publisher: Public Library of Science

Author(s): Sara E. McEwen, Michelle Donald, Katelyn Jutzi, Kay-Ann Allen, Lisa Avery, Deirdre R. Dawson, Mary Egan, Katherine Dittmann, Anne Hunt, Jennifer Hutter, Sylvia Quant, Jorge Rios, Elizabeth Linkewich, Alessandra Solari.


The Cognitive Orientation to daily Occupational Performance (CO-OP) approach is a complex rehabilitation intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. A multi-faceted, supported, knowledge translation (KT) initiative was targeted at the implementation of CO-OP in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals. The study objective was to estimate changes in rehabilitation clinicians’ knowledge, self-efficacy, and practice related to implementing CO-OP.

A single arm pre-post and 6-month follow up study was conducted. CO-OP KT consisted of a 2-day workshop, 4 months of implementation support, a consolidation session, and infrastructure support. In addition, a sustainability plan was implemented. Consistent with CO-OP principles, teams were given control over specific implementation goals and strategies. Multiple choice questions (MCQ) were used to assess knowledge. A self-efficacy questionnaire with 3 subscales (Promoting Cognitive Strategy Use, PCSU; Client-Focused Therapy, CFT; Top-Down Assessment and Treatment, TDAT) was developed for the study. Medical record audits were used to investigate practice change. Data analysis for knowledge and self-efficacy utilized mixed effects models. Medical record audits were analyzed with frequency counts and chi-squares.

Sixty-five health care providers consisting mainly of occupational and physical therapists entered the study. Mixed effects models revealed intervention effects for MCQs, CFT, and PCSU at post intervention and follow-up, but no effect on TDAT. No charts showed any evidence of CO-OP use at baseline, compared to 8/40 (20%) post intervention. Post intervention there was a trend towards reduction in impairment goals and significantly more component goals were set (z = 2.7, p = .007).

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While it is well established that implementing even a relatively simple practice change can be challenging, few studies have examined the implementation of a complex intervention in inter-professional, multi-site environments. A group of knowledge users and researchers in a large urban centre in Canada embarked on such a project in stroke rehabilitation, to address two concerns: One, persons with cognitive impairments following a stroke had decreased access to inpatient rehabilitation [1], despite evidence of its benefits for them [2]; and two, when rehabilitation was accessed, persons with cognitive impairment received services based on outdated impairment-reduction models, rather than recommended function-based approaches [3]. There was evidence to suggest that these two issues could be traced back to a reported lack of skills and knowledge on the part of stroke rehabilitation teams to work with persons with cognitive impairments [3]. A multi-faceted, supported, knowledge translation (KT) initiative, targeted specifically at the inter-professional application of the Cognitive Orientation to daily Occupational Performance (CO-OP) approach in inpatient stroke rehabilitation teams at five freestanding rehabilitation hospitals [4] was implemented and evaluated. CO-OP is a person-centred treatment approach, framed around the use of cognitive strategies, which is aligned with Canadian Stroke Best Practice Recommendations for cognitive rehabilitation [5]. The project, called CO-OP KT, has three embedded studies related to client outcomes; provider knowledge, self-efficacy, and practice; and health system level changes in access to inpatient rehabilitation for persons with cognitive impairments. The protocol for the larger project has been published [6]. The focus of this paper is on findings related to changes in providers’ knowledge, self-efficacy, and practice to implement a cognitive-strategy-based approach following the CO-OP KT intervention.

This study is one of three sub-studies within a larger project; the current study examines health care provider outcomes, another examines health system level outcomes, and a third examines patient level outcomes. The study involving patient outcomes was registered in 2016 on NIH’s website, registration #NCT02597569. A single arm pre-post-follow up study was conducted with stroke rehabilitation clinicians from five publicly-funded, freestanding rehabilitation hospitals in a Toronto, Ontario, Canada. Research Ethics Board approval was obtained from the Mount Sinai Hospital Research Ethics Board, the Providence Healthcare Research Ethics Board, the Sunnybrook Health Sciences Centre Research Ethics Board, the University Health Network Research Ethics Board, and the West Park Healthcare Centre Joint Research Ethics Board. All clinicians who were invited to complete the questionnaires provided informed consent. Patient data were extracted from medical charts and the ethics committees waived consent.

The flow of health care provider participants in this study are displayed in the CONSORT diagram, Fig 1. Sixty-five health care providers entered the study at T1. Regarding responses to the MCQ and SERTA, 20% (n = 13) withdrawal rate occurred by T2 (within the month following the workshop), with an additional 20% (n = 13) withdrawal at T3 and 6% (n = 4) more at T4. Thus, the overall withdrawal rate by the T4 follow-up was 46%. Of the 46%, 12 participants (40%) were not working at the site (e.g., changed jobs, went on leave, etc.), while 18 participants (60%) were still part of the team but did not respond to the surveys for unknown reasons.

The CO-OP KT intervention was associated with significant improvements in knowledge, aspects of self-efficacy, and aspects of practice related to the multi-site implementation of the CO-OP Approach in inter-professional stroke rehabilitation teams. Knowledge, self-efficacy in promoting cognitive strategy use and self-efficacy in client-focused therapy were all maintained 6-months after the CO-OP KT intervention ended. There was no significant change in self-efficacy for using a top-down approach. Changes in knowledge occurred after the workshop and were largely maintained but not augmented during the support period, whereas changes in self-efficacy occurred predominantly during the support period rather than after the workshop. The audit of medical records revealed some limited evidence of practice change. In this discussion, we suggest mechanisms that may have influenced the improvements in knowledge and self-efficacy, suggest potential reasons why change did not occur in self-efficacy for top-down approaches, expand on the findings from the audit of medical records, and outline study limitations and future directions.

CO-OP is a complex clinical intervention in which clients are taught to use problem-solving cognitive strategies to acquire personally-meaningful functional skills, and health care providers are required to shift control regarding treatment goals and intervention strategies to their clients. In using an inter-professional multi-faceted KT intervention in which similar principles were applied (i.e. control over implementation goals and strategies was shifted from researchers to the participating teams), documented practice change was present but limited, and sustained improvements in health care providers’ knowledge and aspects of self-efficacy.




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