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Article

Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial

by
Katie E. Powers
1,*,
Roshan das Nair
2,3,
Julie Phillips
1,
Amanda Farrin
4 and
Kathryn A. Radford
1
1
Injury, Inflammation & Recovery Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham NG7 2UH, UK
2
Health Division, SINTEF, 7465 Trondheim, Norway
3
Mental Health & Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham NG7 2UH, UK
4
Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds LS2 9JT, UK
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2023, 20(6), 4694; https://doi.org/10.3390/ijerph20064694
Submission received: 23 January 2023 / Revised: 24 February 2023 / Accepted: 28 February 2023 / Published: 7 March 2023
(This article belongs to the Special Issue Advances in Modern Rehabilitation, Physiotherapy and Occupational Therapy)
Review Reports Versions Notes

Abstract

:
Understanding what attributes or characteristics of those delivering interventions affect intervention fidelity and patient outcomes is important for contextualising intervention effectiveness. It may also inform implementation of interventions in future research and clinical practice. This study aimed to explore the relationships between attributes of Occupational Therapists (OTs), their faithful delivery of an early stroke specialist vocational rehabilitation intervention (ESSVR), and stroke survivor return-to-work (RTW) outcomes. Thirty-nine OTs were surveyed about their experience and knowledge of stroke and vocational rehabilitation and were trained to deliver ESSVR. ESSVR was delivered across 16 sites in England and Wales between February 2018 and November 2021. OTs received monthly mentoring to support ESSVR delivery. The amount of mentoring each OT received was recorded in OT mentoring records. Fidelity was assessed using an intervention component checklist completed using retrospective case review of one randomly selected participant per OT. Linear and logistic regression analyses explored relationships between OT attributes, fidelity, and stroke survivor RTW outcome. Fidelity scores ranged from 30.8 to 100% (Mean: 78.8%, SD: 19.2%). Only OT engagement in mentoring was significantly associated with fidelity (b = 0.29, 95% CI = 0.05–0.53, p < 0.05). Increased fidelity (OR = 1.06, 95% CI = 1.01–1.1, p = 0.01) and increasing years of stroke rehabilitation experience (OR = 1.17, 95% CI = 1.02–1.35) was significantly associated with positive stroke survivor RTW outcomes. Findings of this study suggest that mentoring OTs may increase fidelity of delivery of ESSVR, which may also be associated with positive stroke survivor return-to-work outcomes. The results also suggest that OTs with more experience of stroke rehabilitation may be able to support stroke survivors to RTW more effectively. Upskilling OTs to deliver complex interventions, such as ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity.

1. Introduction

Results of intervention studies typically only report whether an intervention is shown to attain target outcomes, but attention is not often afforded to more nuanced considerations around intervention implementation [1,2,3]. Understanding the implementation of an intervention can provide helpful information about why or how an intervention did or did not attain the targeted outcomes [4,5,6]. This is especially true of ‘complex’ interventions which comprise numerous components, require certain expertise, skills, and behaviours of those delivering and receiving the intervention, and target multiple groups and settings [7,8]. A complex intervention often requires its components to be modified to fit the needs of those delivering or receiving the intervention [7,8], in these instances it is important to consider ‘fidelity’ or the extent to which an intervention is delivered [9,10,11,12].
Fidelity assessment can be useful not just as an implementation technique to monitor and support healthcare professionals delivering an intervention over the course of the study period [13,14,15], but also to help researchers contextualise the results of a study. Despite the importance of measuring fidelity, systematic reviews have shown that fidelity assessments are rarely conducted [16,17,18], or in cases where assessment has occurred, reported [19,20]. Higher levels of fidelity in studies of complex behaviour change interventions are linked to better patient outcomes [21,22,23,24], which suggests it is important for researchers to understand what factors promote fidelity. Achieving fidelity in some complex intervention studies can be difficult and studies within implementation research have therefore highlighted the importance for thorough investigation into factors which may influence fidelity outcomes [25,26,27]. Due to the number of stakeholders involved in the delivery and receipt of complex interventions, the influence of individual-level attributes on fidelity outcomes is of particular interest [14,28].
Individual-level attributes are personal characteristics that can be stable, i.e., thought to stay the same over time (e.g., education, openness to change, critical thinking) [29] or unstable, which are subject to change over time (practice, engagement, illness) [30]. Studies of the factors affecting the implementation of evidence-based practice (EBP) have shown that attributes of both healthcare professionals and patients may contribute to poor fidelity outcomes, or implementation failure [31,32,33]. Research regarding what therapist attributes (e.g., gender, years of experience, level of education, etc.) impact fidelity outcomes is inconsistent and inconclusive [14,34,35]. For example, while years since qualifying as a therapist does not demonstrate clear directionality [14,34,35], experience in skills related to an intervention improves fidelity rates [36]. Therapists’ positive attitudes and beliefs towards EPB [28,37], greater competency [38,39], and greater self-efficacy [40,41] have been found to consistently, considerably, and positively affect either fidelity or patient outcome across patient groups, intervention type, and setting [42,43,44]. Most studies exploring the impact of therapist attribute on fidelity outcomes are within studies of interventions delivered by psychotherapists (as detailed in systematic reviews) [43,44]. Research within complex intervention studies delivered by other professions outside of psychotherapy is lacking and inconclusive.
Vocational rehabilitation (VR) is an intervention that supports people in returning to or remaining in work [45]. Many long-term neurological conditions, including stroke, can affect a person’s ability to stay in or return-to-work. VR interventions are considered complex because they contain many interacting parts that are influenced by many different contexts and factors [46]. The delivery of VR requires the intervention to be tailored to the person receiving it, being sensitive to the changing behaviours of the different stakeholders or those delivering, receiving, and affected by the intervention. It crosses organisational boundaries and can produce a variety of outcomes [32]. Occupational therapists are healthcare professionals who support people’s activities of daily living and are therefore well-situated to deliver VR. VR interventions have been studied in stroke survivor populations [47,48], but there is no reported measurement of implementation considerations, such as fidelity or the individual-level attributes, that might be affect implementation or outcomes. Without information regarding the context around intervention delivery, confident conclusions regarding study results and intervention effectiveness are not possible, and the likelihood of patients receiving potentially life-changing intervention is diminished.
This study sought to explore the relationships between OT attributes, implementation fidelity, and stroke survivor return-to-work outcomes and was conducted using data collected from the RETurn to work After stroKE (RETAKE) trial (ISRCTN: 12464275); a large multi-centre randomised controlled trial (RCT) of a complex, VR intervention to support stroke survivors to return to and stay in work following their stroke.

2. Materials and Methods

We used a correlational design drawing on qualitative and quantitative data from RETAKE OTs and stroke survivors in the RETAKE trial intervention group to explore the relationships between OT attributes, implementation fidelity, and stroke survivor RTW outcome at 12-month post-randomisation in the RETAKE trial (Trial Registration: ISRCTN, ISRCTN12464275. Registered on 13 March 2018). Ethical approval for the RETAKE trial and the studies within the trial was obtained through the East Midlands–Nottingham 2 Research Ethics Committee (REC) (Ref: 18/EM/0019).

2.1. Participants

We recruited at least two OTs from each of RETAKE’s 16 study sites across England and Wales to be trained to deliver the intervention. Aside from being a qualified OT, there were no other inclusion/exclusion criteria for OT recruitment, but previous experience of stroke and VR in community settings was desirable.
Stroke survivors who were recruited to the RETAKE study [49], and whose data were included in this study, were required to be:
  • Aged 18 years or older;
  • Admitted to a hospital with a new stroke prior to recruitment;
  • Working at the time of their stroke (paid or unpaid, for at least two hours per week);
  • Have the capacity to provide informed consent for participation;
  • Sufficient English language proficiency to participate in the study.
Stroke survivors who did not intend to return-to-work were excluded.

2.2. Early Stroke Specialist Vocational Rehabilitation

Early stroke specialist vocational rehabilitation (ESSVR) combines conventional VR with case management. It is delivered by a stroke specialist OT who is trained to assess the impact of the stroke on the stroke survivor and their job; coordinate appropriate support from the National Health Service (NHS), employers and other stakeholders; negotiate workplace adjustments, monitor return-to-work, and explore alternatives where current work is not feasible or cannot be maintained [50]. ESSVR is delivered to community-dwelling stroke survivors in four stages (early recovery, graded return-to-work, job retention, and discharge), each comprising several core and desirable components. More information regarding the RETAKE trial and ESSVR can be found in the trial protocol [49].

2.3. Training for Occupational Therapists

OTs were invited to attend a two-day, manualised, face-to-face training session facilitated by expert trainers and mentors in VR. The aim of the session was to acquaint the OTs with the components of the intervention and the research process. Following their initial training, the OTs were also encouraged to attend monthly, hour-long mentoring sessions to receive ongoing mentoring support from an OT with expertise in VR. The aim of mentoring was to support the OTs to deliver the intervention with fidelity and to foster peer support through discussion of the OTs’ active ESSVR cases and sharing best practice. OTs were encouraged to contact their mentor outside of group mentoring if further support was needed. OTs attended a one-day, in-person, refresher training session six months after their initial training session.

2.4. Measures of OT Attributes

2.4.1. Previous Experience and Knowledge

We designed a form to capture information about the OTs’ education levels, and years of experience in OT, stroke rehabilitation, and VR. The form also asked whether OTs had recent experience of health research (yes or no) and theoretical knowledge of VR (yes or no).

2.4.2. Competency

OTs’ competency to deliver the intervention was assessed at three different timepoints: immediately following the two-day initial ESSVR training session, following the refresher training session held six months after training, and twelve months after the initial training session. At the initial and six-month competency assessments, the OTs were provided a vignette (that illustrated a case study) and the OT was asked to create a treatment plan. To assess competency at the third timepoint, OTs were asked to send completed intervention records from the first stroke survivor they treated nine months after their initial training session. This was performed to ensure that the therapists would theoretically be evaluated based on their treatment of a participant at their most experienced point of intervention delivery. In cases where OTs did not have nine months experience of delivering the intervention, the intervention records for their last treated stroke survivor were requested.
Competency was assessed by the central training team comprising two OTs with expertise in the ESSVR intervention and OT research. OT responses were marked against a rubric assessing their knowledge, clinical reasoning, and written communication. These scores were used to categorise competency as ‘needs support’, ‘competent’, and ‘highly competent’. Assessments were independently double-marked and any discrepancies that affected classification were discussed and agreed between the two raters.

2.4.3. Engagement with Mentoring

The amount of contact each OT had with their mentor, inside and outside of their mentoring group, was recorded in minutes. Mentoring was summarised over two time periods, the amount of mentoring each OT received before their selected fidelity case began, and the amount of mentoring received during their selected fidelity case.

2.5. Fidelity Assessment

The fidelity assessment used a retrospective review of stroke survivor intervention records that included session content case report forms (CRFs), OT clinical notes, and correspondence between the OT, stroke survivors and other key stakeholders to assess intervention fidelity (see Table 1). Stroke survivor intervention records that were collected for competency assessment were also used for the fidelity assessment (see above). Once the stroke survivor intervention records were obtained, researchers (KP, JP) used an ESSVR-specific fidelity checklist and its associated guidance notes to assess component delivery. The total fidelity assessment score was calculated based on the number of components delivered divided by the total number of components that were deliverable and multiplied by 100 to provide a percentage of fidelity (0–100%). More information regarding the development and psychometric properties of the ESSVR fidelity checklist can be found elsewhere [51].

2.6. Return-to-Work Outcome

Stroke survivor RTW outcome was assessed 12 months post-randomisation. Stroke survivors were asked whether they had returned to work (yes or no). The definition of RTW in this study was “return to paid or unpaid work, for at least two hours per week”. This could include returning to the previous role or working in a new role.

2.7. Statistical Methods

A series of univariate linear regression analyses were performed to identify any potential predictors. Statistically significant results were adjusted for potential confounding factors. In cases where more than one variable was found to predict the fidelity score, a multivariate linear regression analysis was conducted.

3. Results

3.1. Description of Occupational Therapists

Data on therapist-level attributes were collected between February 2018 and November 2020. A total of 46 OTs across 16 sites were recruited and trained to deliver ESSVR. Of these, 39 OTs sent the stroke survivor intervention records as requested (one stroke survivor per OT, n = 39). Non-response was due to illness (n = 2) and no recruitment of ESSVR participants (n = 3), For demographic characteristics of the OTs see Table 2.

3.2. Fidelity Scores

Fidelity assessment score ranged from 30.8% to 100%, with an average score of 78.8% (SD: 19.2%).

3.3. OT Attributes

3.3.1. Relationship between OT Attributes and Fidelity Assessment Score

Data regarding experience, post-training competence, engagement with mentoring, and fidelity assessment were collected and analysed for all 39 OTs. Of the nine OT attributes analysed through a series of simple linear regression calculations, only an average amount of mentoring received per month was a significant predictor of fidelity assessment score (F(1, 37) = 6.21, p < 0.05, with an R2 of 0.12). OTs’ predicted fidelity assessment score was equal to 67.86 + 0.29% (minutes of mentoring). Fidelity assessment score increased 0.29% for each minute of mentoring received per month. This effect remained significant when adjusted for potential confounding variables (experience, knowledge, and total previous amount of mentoring received).
See Table 3 for the individual relationships between OT attributes and fidelity assessment score.

3.3.2. Relationships between OT Attributes and Stroke Survivor RTW Outcomes

Univariate logistic regression was conducted to explore and identify attributes that might be associated with the likelihood that stroke survivors would RTW following ESSVR delivery. Increase in years of stroke rehabilitation experience (OR = 1.16, 95% CI [1.02, 1.32]), increase in average minutes of mentoring received monthly (OR = 1.03, 95% CI [1.0, 1.07]), and fidelity assessment score (OR = 1.06, 95% CI [1.01, 1.1]) were found to be independently associated with increased likelihood of a stroke survivor’s RTW (See Table 4). The attributes shown to be independently associated with increased likelihood of RTW were included in a multivariate logistic analysis.
A multivariate logistic regression analysis was performed to further explore the relationship between OT stroke rehabilitation experience and fidelity of ESSVR delivery on the likelihood that stroke survivors would RTW following ESSVR. The logistic regression model was statistically significant [X2 (2, N = 39) = 14.07, p = 0.001]. The model explained 30.3% (Cox and Snell R2) of the of the variance in RTW outcome. Increasing years of stroke rehabilitation experience (OR = 1.17, 95% CI [1.02, 1.35]) and increasing fidelity assessment score (OR = 1.06, 95% CI [1.01, 1.1]) was associated with an increase in the likelihood of returning to work (See Table 5).

4. Discussion

Little evidence exists regarding what therapist attributes might impact fidelity and patient outcomes in complex rehabilitation interventions outside of the psychotherapy literature. This study found that only greater amounts of mentoring received per month during the stroke survivor case selected for fidelity assessment was associated with higher rates of fidelity to ESSVR delivery, and that more experience of stroke rehabilitation and higher fidelity rates were associated a greater likelihood of stroke survivor return-to-work at 12 months post-randomisation.
Despite the importance of assessing fidelity in clinical trials, it is a construct often overlooked in occupational therapy interventions. The OTs in the present study were able to deliver ESSVR with 78.8% fidelity on average, which is relatively high compared with other studies with similar evaluations [52,53]. These findings suggest that ESSVR was delivered with acceptable (70% or higher) rates of fidelity and that the wider RETAKE trial might not be impacted by issues of poor fidelity.
Engagement with mentoring is predictive of fidelity in interventions delivered by OTs in other studies [54]. The complexity and individualisation required by ESSVR in combination with the observation that the average amount of engagement per month, not the total amount of mentoring previously received was predictive of fidelity assessment score, might suggest that while mentoring does not necessarily develop OTs into experts in ESSVR, ongoing engagement with mentoring might support the OTs to deliver ESSVR with fidelity. This might be due to the structure of the mentoring in RETAKE, which created opportunity for further knowledge acquisition and peer support as well as supervision from an expert mentor [55,56]. These results, taken with the results of Döpp and colleagues’ [54] study, suggest that mentoring might be an effective implementation strategy for OTs delivering complex interventions. The finding that the total amount of mentoring received was not associated with fidelity is surprising, and future research should consider what further experience or training would be required to facilitate OTs reaching an ‘expert’ level of delivery in ESSVR. Regardless, future studies of complex interventions should consider the inclusion of a mentoring programme and encourage the therapists to engage with the programme to support fidelity of intervention delivery.
Higher rates of fidelity have long been associated with more positive patient treatment outcomes [25,57]. The results of the present study reinforce such findings. What is surprising is that the OTs’ previous experience of stroke rehabilitation was related to the return-to-work outcome, but not their previous experience of vocational rehabilitation. OTs with more years of experience in stroke rehabilitation maybe able to better understand the contextual factors that would prevent someone from returning to work after their stroke which in turn might lead to the OT individualising ESSVR in a way that more efficiently supports the stroke survivor to return-to-work. Further research is required to understand this relationship. Mentoring may have helped OTs with a wide range of VR experience to deliver ESSVR with fidelity. This suggests that consistent, timely mentoring support may be more important in the implementation of VR than previous experience of delivering it.
In our study, initial competence to deliver ESSVR was hypothesized to be a factor with the potential to influence fidelity outcomes because it has previously been demonstrated as a predictive factor of implementation fidelity in other studies [28,58]. Contrary to the previous evidence, therapist competence was not indicative of fidelity in this study. However, this discrepancy may be because the amount of time between the OTs’ initial competency assessment and the case sampled for fidelity assessment varied greatly, with most OTs having at least six months of experience before starting the intervention with the stroke survivor selected for fidelity assessment. Most OTs (n = 34; 87%) also attended their refresher training session. In the time elapsed between their initial training and their selected fidelity assessment case, the OTs built on their initial competence and understanding of the intervention. Future studies might investigate this further by measuring attributes at additional timepoints and exploring the changes in attributes over time that might occur due to involvement in clinical research and engagement with intervention training.
This study’s limitations should be seen in light of the exploratory nature of the study, coupled with the scarcity of other such occupational therapy and VR research attempting to explore the relationships between therapist attributes, fidelity, and treatment outcomes outside of psychotherapy. This is an important consideration because whilst psychotherapy is also a complex intervention, it is different from VR and is typically delivered by a non-occupational therapy workforce. Therefore, we cannot assume that the research findings from the field of psychotherapy necessarily translate/transfer to VR- and OT-delivered interventions.
This study included large numbers of potential predictor variables and limited numbers of OTs and stroke survivors. Because of the small sample size, we were unable to explore in depth the interactions between the predictor variables themselves. The small sample of OTs in this study mostly included women (which is representative of the national picture of the profession, with 91% of OTs being women) [59] with relatively little self-reported recent research experience. However, it is however difficult to generalise the results of the study to a larger population of OTs who might have more extensive research experience.
To assess fidelity in this study, OTs were asked for a specified stroke survivor’s intervention records to which a fidelity checklist [51] was applied. Fidelity checklist completion was dependent on the record keeping of the OTs and completeness of the intervention records, which limits fidelity conclusions to ‘evidence of’ the delivery of components. OTs were trained to maintain their intervention records in a way that was easily accessible for the research team; however, it is possible that OTs might not have recorded evidence of component delivery. Additionally, this study sampled one stroke survivor’s intervention records per OT, which begs the consideration that the cases sampled might not be a true reflection of the OTs’ actual overall fidelity. Future studies might look to examine several stroke survivors per OT and explore the changes in fidelity assessment score over time and the factors associated with those changes.
This study did not explore the impact of stroke survivor attributes on return-to-work outcome. There is a plethora of systematic reviews examining predictors of return-to-work after stroke which have identified attributes related to high likelihood of returning to work after a stroke, such as milder stroke severity [60], being male [61], and having independence in activities of daily living [61]. What is lacking from these systematic reviews, and from studies of return-to-work after stroke more generally, is greater consideration of the impact of work-related attributes (such as the adaptability of the stroke survivor’s role or the relationships with employers), which should be considered in future studies. The present study also did not consider the impact of organisational factors, which would have provided further context for the environment in which the OTs were delivering the intervention. For example, pressure for service development and organisational motivation to address the needs of a changing healthcare climate are factors that are associated with greater therapist fidelity rates [62]. Additionally, resource availability (i.e., adequate staffing, capacity, and service financial resources) might negatively impact fidelity and should be considered in future studies.
We suggest that providing support from expert mentors to OTs is a key implementation strategy for ensuring the faithful delivery of ESSVR and similar interventions. Future research should seek to further explore the mechanisms of action within mentoring to understand what underlying mechanisms of the mentoring might be facilitating delivery with fidelity (e.g., peer support, discussion of cases, etc.). Future studies should seek to include higher numbers of therapists and stroke survivors to achieve the statistical power needed to explore the relationships between attributes, fidelity, and patient outcomes more effectively [12,63,64].

5. Conclusions

Taken together, the findings of this study suggest that upskilling OTs to deliver complex interventions, such as ESSVR, in clinical trials may require mentoring support in addition to training to ensure fidelity. Furthermore, providing mentoring to ensure intervention fidelity may positively influence individual participant outcomes in return-to-work after stroke.

Author Contributions

Conceptualization, K.E.P., K.A.R. and R.d.N.; methodology, K.E.P., R.d.N., J.P., A.F. and K.A.R.; software, K.E.P.; validation, K.E.P. and J.P.; formal analysis, K.E.P.; investigation, K.E.P., K.A.R. and J.P.; resources, K.E.P., K.A.R., A.F. and J.P.; data curation, K.E.P. and J.P.; writing—original draft preparation, K.E.P.; writing—review and editing, K.E.P., J.P., R.d.N., A.F. and K.A.R.; visualization, K.E.P.; supervision, K.A.R., R.d.N. and A.F.; project administration, K.E.P.; funding acquisition, K.A.R. All authors have read and agreed to the published version of the manuscript.

Funding

This article includes research funded by the National Institutes of Health Research Health Technology Assessment programme (NIHR-HTA; ref: 15/130/11). The views expressed in this article are those of the authors, not necessarily the NIHR, the Department of Health and Social Care, or the NHS. Katie Powers’ PhD is funded by the Ossie Newell Foundation and the views expressed in this article are those of the authors, not necessarily the Ossie Newell Foundation.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and ethical approval has been obtained through the East Midlands—Nottingham 2 Research Ethics Committee (REC) (Ref: 18/EM/0019).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

On study completion, the final trial dataset will be archived at the University of Nottingham. Following completion of the RETAKE trial and publication of its effectiveness outcomes, any party may apply to the corresponding author for access to the dataset. Access will be governed by an information governance committee formed between The University of Nottingham and the University of Leeds.

Acknowledgments

The authors wish to thank the RETAKE stroke survivors and Occupational Therapists for their contribution to the data collected for this study.

Conflicts of Interest

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

References

  1. O’Shea, O.; McCormick, R.; Bradley, J.M.; O’Neill, B. Fidelity review: A scoping review of the methods used to evaluate treatment fidelity in behavioural change interventions. Phys. Ther. Rev. 2016, 21, 207–214. [Google Scholar] [CrossRef] [Green Version]
  2. Slaughter, S.E.; Hill, J.N.; Snelgrove-Clarke, E. What is the extent and quality of documentation and reporting of fidelity to implementation strategies: A scoping review. Implement. Sci. 2015, 10, 129. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  3. Walton, H.; Spector, A.; Tombor, I.; Michie, S. Measures of fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions: A systematic review of measure quality. Br. J. Health Psychol. 2017, 22, 872–903. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  4. Lockett, H.; Waghorn, G.; Kydd, R. A framework for improving the effectiveness of evidence-based practices in vocational rehabilitation. J. Vocat. Rehabil. 2018, 49, 15–31. [Google Scholar] [CrossRef]
  5. McGee, D.; Lorencatto, F.; Matvienko-Sikar, K.; Toomey, E. Surveying knowledge, practice and attitudes towards intervention fidelity within trials of complex healthcare interventions 11 Medical and Health Sciences 1117 Public Health and Health Services. Trials 2018, 19, 1–14. [Google Scholar] [CrossRef]
  6. Nilsen, P. Making sense of implementation theories, models, and frameworks. In Implementation Science 3.0; Springer: Berlin/Heidelberg, Germany, 2020; pp. 53–79. [Google Scholar]
  7. Craig, P.; Dieooe, P.; Macintyre, S.; Michie, S.; Nazareth, I.; Petticrew, M. Developing and evaluating complex interventions: Folloving considerable development in the field since 2006, MRC and NIHR have jointly commissionned an update of this guidance to be published in 2019. Med. Res. Counc. 2008, 337, a1655. Available online: https://mrc.ukri.org/documents/pdf/complex-interventions-guidance/ (accessed on 5 May 2022).
  8. Skivington, K.; Matthews, L.; Simpson, S.A.; Craig, P.; Baird, J.; Blazeby, J.M.; Boyd, K.A.; Craig, N.; French, D.P.; McIntosh, E.; et al. A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ 2021, 374. [Google Scholar] [CrossRef]
  9. Bellg, A.J.; Borrelli, B.; Resnick, B.; Hecht, J.; Minicucci, D.S.; Ory, M.; Ogedegbe, G.; Orwig, D.; Ernst, D.; Czajkowski, S. Enhancing Treatment Fidelity in Health Behavior Change Studies: Best Practices and Recommendations From the NIH Behavior Change Consortium. Heal. Psychol. 2004, 23, 443–451. [Google Scholar] [CrossRef]
  10. Borrelli, B.; Sepinwall, D.; Ernst, D.; Bellg, A.J.; Czajkowski, S.; Breger, R.; DeFrancesco, C.; Levesque, C.; Sharp, D.L.; Ogedegbe, G.; et al. A new tool to assess treatment fidelity and evaluation of treatment fidelity across 10 years of health behavior research. J. Consult. Clin. Psychol. 2005, 73, 852–860. [Google Scholar] [CrossRef] [PubMed]
  11. Gearing, R.E.; El-Bassel, N.; Ghesquie, A.; Baldwin, S.; Gillies, J.; Ngeow, E. Major ingredients of fidelity: A review and scientific guide to improving quality of intervention research implementation. Clin. Psychol. Rev. 2011, 31, 79–88. [Google Scholar] [CrossRef]
  12. Perepletchikova, F.; Treat, T.A.; Kazdin, A.E. Treatment Integrity in Psychotherapy Research: Analysis of the Studies and Examination of the Associated Factors. J. Consult. Clin. Psychol. 2007, 75, 829–841. [Google Scholar] [CrossRef] [PubMed]
  13. Forsberg, S.; Fitzpatrick, K.K.; Darcy, A.; Aspen, V.; Accurso, E.C.; Bryson, S.W.; Agras, S.; Arnow, K.D.; Le Grange, D.; Lock, J. Development and evaluation of a treatment fidelity instrument for family-based treatment of adolescent anorexia nervosa. Int. J. Eat. Disord. 2015, 48, 91–99. [Google Scholar] [CrossRef] [Green Version]
  14. Sijercic, I.; Lane, J.E.M.; Gutner, C.A.; Monson, C.M.; Stirman, S.W. The Association Between Clinician and Perceived Organizational Factors with Early Fidelity to Cognitive Processing Therapy for Posttraumatic Stress Disorder in a Randomized Controlled Implementation Trial. Adm. Policy Ment. Health Ment. Health Serv. Res. 2020, 47, 8–18. [Google Scholar] [CrossRef]
  15. Thijssen, J.; Albrecht, G.; Muris, P.; de Ruiter, C. Treatment fidelity during therapist initial training is related to subsequent effectiveness of parent management training—Oregon model. J. Child Fam. Stud. 2017, 26, 1991–1999. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  16. Dalgetty, R.; Miller, C.B.; Dombrowski, S.U. The theory-effectiveness hypothesis: A systematic review of systematic reviews. Br. J. Health Psychol. 2019, 24, 334–356. [Google Scholar] [CrossRef] [PubMed]
  17. O’Halloran, P.D.; Blackstock, F.; Shields, N.; Holland, A.; Iles, R.; Kingsley, M.; Bernhardt, J.; Lannin, N.; Morris, M.E.; Taylor, N.F. Motivational interviewing to increase physical activity in people with chronic health conditions: A systematic review and meta-analysis. Clin. Rehabil. 2014, 28, 1159–1171. [Google Scholar] [CrossRef]
  18. Waltman, S.H.; Sokol, L.; Beck, A.T. Cognitive behavior therapy treatment fidelity in clinical trials: Review of recommendations. Curr. Psych. Rev. 2017, 13, 311–315. [Google Scholar] [CrossRef]
  19. Copeland, L.; McNamara, R.; Kelson, M.; Simpson, S. Mechanisms of change within motivational interviewing in relation to health behaviors outcomes: A systematic review. Patient Educ. Couns. 2015, 98, 401–411. [Google Scholar] [CrossRef]
  20. Spencer, J.C.; Wheeler, S.B. A systematic review of Motivational Interviewing interventions in cancer patients and survivors. Patient Educ. Couns. 2016, 99, 1099–1105. [Google Scholar] [CrossRef]
  21. Farmer, C.C.; Mitchell, K.S.; Parker-Guilbert, K.; Galovski, T.E. Fidelity to the cognitive processing therapy protocol: Evaluation of critical elements. Behav. Ther. 2017, 48, 195–206. [Google Scholar] [CrossRef] [PubMed]
  22. Marques, L.; Valentine, S.E.; Kaysen, D.; Mackintosh, M.A.; Dixon De Silva, L.E.; Ahles, E.M.; Youn, S.J.; Shtasel, D.L.; Simon, N.M.; Wiltsey-Stirman, S. Provider fidelity and modifications to cognitive processing therapy in a diverse community health clinic: Associations with clinical change. J. Consult. Clin. Psychol. 2019, 87, 357–369. [Google Scholar] [CrossRef] [PubMed]
  23. McHugo, G.J.; Drake, R.E.; Teague, G.B.; Xie, H. Fidelity to assertive community treatment and client outcomes in the New Hampshire dual disorders study. Psychiatr. Serv. 1999, 50, 818–824. [Google Scholar] [CrossRef] [PubMed]
  24. Strunk, D.R.; Brotman, M.A.; DeRubeis, R.J. The process of change in cognitive therapy for depression: Predictors of early inter-session symptom gains. Behav. Res. Ther. 2010, 48, 599–606. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  25. Carroll, C.; Patterson, M.; Wood, S.; Booth, A.; Rick, J.; Balain, S. A conceptual framework for implementation fidelity. Implement. Sci. 2007, 2, 40. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  26. Damschroder, L.; Aron, D.; Keith, R.; Kirsh, S.; Alexander, J.; Lowery, J. Fostering Implementation of Health Services Research Findings into Practice: A Consolidated Framework for Advancing Implementation Science. Implement. Sci. 2009, 4, 50. [Google Scholar] [CrossRef] [Green Version]
  27. Hasson, H. Systematic evaluation of implementation fidelity of complex interventions in health and social care. Implement. Sci. 2010, 5, 67. [Google Scholar] [CrossRef] [Green Version]
  28. Wiltsey Stirman, S.; Gutner, C.A.; Crits-Christoph, P.; Edmunds, J.; Evans, A.C.; Beidas, R.S. Relationships between clinician-level attributes and fidelity-consistent and fidelity-inconsistent modifications to an evidence-based psychotherapy. Implement. Sci. 2015, 10, 115. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  29. Flint-Taylor, J.; Davda, A.; Cooper, C.L. Stable personal attributes and a resilient approach to work and career. SA J. Ind. Psychol. 2014, 40, 1–10. [Google Scholar] [CrossRef] [Green Version]
  30. Arnkelsson, G.B.; Smith, W.P. The impact of stable and unstable attributes on ability assessment in social comparison. Personal. Soc. Psychol. Bull. 2000, 26, 936–947. [Google Scholar] [CrossRef]
  31. Grol, R.; Wensing, M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med. J. Aust. 2000, 180, S57–S60. [Google Scholar] [CrossRef]
  32. Hart, T.; Bagiella, E. Design and implementation of clinical trials in rehabilitation research. Arch. Phys. Med. Rehabil. 2012, 93, S117–S126. [Google Scholar] [CrossRef] [PubMed]
  33. Solberg, L.I. Guideline implementation: What the literature doesn’t tell us. Jt. Comm. J. Qual. Improv. 2000, 26, 525–537. [Google Scholar] [CrossRef] [PubMed]
  34. Campbell, B.K.; Buti, A.; Fussell, H.E.; Srikanth, P.; McCarty, D.; Guydish, J.R. Therapist predictors of treatment delivery fidelity in a community-based trial of 12-step facilitation. Am. J. Drug Alcohol Abus. 2013, 39, 304–311. [Google Scholar] [CrossRef]
  35. Carpenter, K.M.; Cheng, W.Y.; Smith, J.L.; Brooks, A.C.; Amrhein, P.C.; Wain, R.M.; Nunes, E.V. Old dogs’ and new skills: How clinician characteristics relate to motivational interviewing skills before, during, and after training. J. Consult. Clin. Psychol. 2012, 80, 560. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  36. James, I.A.; Blackburn, I.; Milne, D.L.; Reichfelt, F.K. Moderators of trainee therapists’ competence in cognitive therapy. Br. J. Clin. Psychol. 2001, 40, 131–141. [Google Scholar] [CrossRef]
  37. McHugh, R.K.; Barlow, D.H. The dissemination and implementation of evidence-based psychological treatments. A review of current efforts. Am. Psychol. 2010, 65, 73–84. [Google Scholar] [CrossRef] [Green Version]
  38. Branson, A.; Myles, P.; Mahdi, M.; Shafran, R. The Relationship between Competence and Patient Outcome with Low-Intensity Cognitive Behavioural Interventions. Behav. Cogn. Psychother. 2018, 46, 101–114. [Google Scholar] [CrossRef]
  39. Campos-Melady, M.; Smith, J.E.; Meyers, R.J.; Godley, S.H.; Godley, M.D. The effect of therapists’ adherence and competence in delivering the adolescent community reinforcement approach on client outcomes. Psychol. Addict. Behav. 2017, 31, 117–129. [Google Scholar] [CrossRef]
  40. Colquhoun, H.L.; Carroll, K.; Eva, K.W.; Grimshaw, J.M.; Ivers, N.; Michie, S.; Sales, A.; Brehaut, J.C. Advancing the literature on designing audit and feedback interventions: Identifying theory-informed hypotheses. Implement. Sci. 2017, 12, 117. [Google Scholar] [CrossRef]
  41. Eccles, M.; Grimshaw, J.; Walker, A.; Johnston, M.; Pitts, N. Changing the behavior of healthcare professionals: The use of theory in promoting the uptake of research findings. J. Clin. Epidemiol. 2005, 58, 107–112. [Google Scholar] [CrossRef]
  42. Wampold, B.E.; Baldwin, S.A.; Grosse Holtforth, M.; Imel, Z.E. What characterizes effective therapists? In How and Why Are Some Therapists Better Than Others? Understanding Therapist Effects; American Psychological Association: Washington, DC, USA, 2017; pp. 37–53. [Google Scholar]
  43. Heinonen, E.; Nissen-Lie, H.A. The professional and personal characteristics of effective psychotherapists: A systematic review. Psychother. Res. 2020, 30, 417–432. [Google Scholar] [CrossRef] [PubMed]
  44. Johns, R.G.; Barkham, M.; Kellett, S.; Saxon, D. A systematic review of therapist effects: A critical narrative update and refinement to Baldwin and Imel’s (2013) review. Clin. Psychol. Rev. 2019, 67, 78–93. [Google Scholar] [CrossRef] [PubMed]
  45. Waddell, G.; Burton, K.; Kendall, N. Vocational Rehabilitation—What Works, for Whom, and When? (Report for the Vocational Rehabilitation Task Group); TSO: London, UK, 2008. [Google Scholar]
  46. Hart, T. Treatment definition in complex rehabilitation interventions. Neuropsychol. Rehabil. 2009, 19, 824–840. [Google Scholar] [CrossRef] [PubMed]
  47. Grant, M. Developing, Delivering and Evaluating Stroke Specific Vocational Rehabilitation: A Feasibility Randomised Controlled Trial. Ph.D. Thesis, University of Nottingham, Nottingham, UK, 2016. Available online: https://www.proquest.com/docview/1913433355?accountid=26642%0Ahttp://link.periodicos.capes.gov.br/sfxlcl41?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&genre=dissertations+%26+theses&sid=ProQ:ProQuest+Dissertations+%26+Theses+Global&a (accessed on 7 May 2022).
  48. Ntsiea, M.V.; Van Aswegen, H.; Lord, S.; Olorunju, S. The effect of a workplace intervention programme on return to work after stroke: A randomised controlled trial. Clin. Rehabil. 2015, 29, 663–673. [Google Scholar] [CrossRef]
  49. Radford, K.A.; Craven, K.; McLellan, V.; Sach, T.H.; Brindle, R.; Holloway, I.; Hartley, S.; Bowen, A.; O’Connor, R.; Stevens, J.; et al. An individually randomised controlled multi-centre pragmatic trial with embedded economic and process evaluations of early vocational rehabilitation compared with usual care for stroke survivors: Study protocol for the return to work After stroKE (RETAKE). Trials 2020, 21, 1010. [Google Scholar] [CrossRef]
  50. Grant, M.; Radford, K.; Sinclair, E.; Walker, M. Return to work after stroke: Recording, measuring, and describing occupational therapy intervention. Br. J. Occup. Ther. 2014, 77, 457–465. [Google Scholar] [CrossRef] [Green Version]
  51. Powers, K.; Clarke, S.; Phillips, J.; Holmes, J.A.; Cripps, R.; Craven, K.; Farrin, A.; das Nair, R.; Radford, K.A. Developing an implementation fidelity checklist for a vocational rehabilitation intervention. Pilot Feasibility Stud. 2022, 8, 234. [Google Scholar] [CrossRef] [PubMed]
  52. Hardeman, W.; Michie, S.; Fanshawe, T.; Prevost, A.T.; McLoughlin, K.; Kinmonth, A.L. Fidelity of delivery of a physical activity intervention: Predictors and consequences. Psychol. Health 2008, 23, 11–24. [Google Scholar] [CrossRef]
  53. Lorencatto, F.; West, R.; Christopherson, C.; Michie, S. Assessing fidelity of delivery of smoking cessation behavioural support in practice. Implement. Sci. 2013, 8, 40. [Google Scholar] [CrossRef] [Green Version]
  54. Döpp, C.M.; Graff, M.J.; Teerenstra, S.; Olde Rikkert, M.G.; Nijhuis–van der Sanden, M.W.; Vernooij-Dassen, M.J. Effectiveness of a training package for implementing a community-based occupational therapy program in dementia: A cluster randomized controlled trial. Clin. Rehabil. 2015, 29, 974–986. [Google Scholar] [CrossRef]
  55. Craven, K.; Holmes, J.; Powers, K.; Clarke, S.; Cripps, R.L.; Lindley, R.; Phillips, J.; Tyerman, R.; McKevitt, C.; Clarke, D.; et al. Embedding mentoring to support trial processes and implementation fidelity in a randomised controlled trial of vocational rehabilitation for stroke survivors. BMC Med. Res. Methodol. 2021, 21, 203. [Google Scholar] [CrossRef]
  56. Santacroce, S.J.; Maccarelli, L.M.; Grey, M. Intervention fidelity. Nurs. Res. 2004, 53, 63–66. [Google Scholar] [CrossRef] [PubMed]
  57. Durlak, J.A.; DuPre, E.P. Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am. J. Community Psychol. 2008, 41, 327–350. [Google Scholar] [CrossRef]
  58. Beck, A.K.; Baker, A.L.; Carter, G.; Robinson, L.; McCarter, K.; Wratten, C.; Bauer, J.; Wolfenden, L.; Britton, B. Is fidelity to a complex behaviour change intervention associated with patient outcomes? Exploring the relationship between dietitian adherence and competence and the nutritional status of intervention patients in a successful stepped-wedge randomised clinical trial of eating as treatment (EAT). Implement. Sci. 2012, 16, 46. [Google Scholar] [CrossRef]
  59. Health and Care Professions Council. HCPC Diversity Data Report 2021: Occupational Therapists; Health and Care Professions Council: London, UK, 2021. [Google Scholar]
  60. Ashley, K.D.; Lee, L.T.; Heaton, K. Return to Work Among Stroke Survivors. Workplace Health Saf. 2019, 67, 87–94. [Google Scholar] [CrossRef]
  61. Edwards, J.D.; Kapoor, A.; Linkewich, E.; Swartz, R.H. Return to work after young stroke: A systematic review. Int. J. Stroke 2018, 13, 243–256. [Google Scholar] [CrossRef] [PubMed]
  62. Henggeler, S.W.; Sheidow, A.J.; Cunningham, P.B.; Donohue, B.C.; Ford, J.D. Promoting the implementation of an evidence-based intervention for adolescent marijuana abuse in community settings: Testing the use of intensive quality assurance. J. Clin. Child Adolesc. Psychol. 2008, 37, 682–689. [Google Scholar] [CrossRef] [PubMed]
  63. Cox, D.; Grus, C. From Continuing Education to Continuing Competence. Prof. Psychol. Res. Pract. 2019, 50, 113–119. [Google Scholar] [CrossRef]
  64. Southam-Gerow, M.A.; Chapman, J.E.; Martinez, R.G.; McLeod, B.D.; Hogue, A.; Weisz, J.R.; Kendall, P.C. Are therapist adherence and competence related to clinical outcomes in cognitive-behavioral treatment for youth anxiety? J. Consult. Clin. Psychol. 2021, 89, 188–199. [Google Scholar] [CrossRef]
Table
Table 1. Brief descriptions of the components of the stroke survivor intervention records.
Table 1. Brief descriptions of the components of the stroke survivor intervention records.
Intervention Record ComponentDescription
Content CRFsOTs indicate which components of the intervention and other common OT practices were delivered in a session.
Therapist clinical notesOT notes from each instance of contact with the stroke survivor or other key stakeholders.
Supplementary materialExtra materials provided in the case file. Includes:
  • Evidence of correspondence (e.g., copies of emails and written communication to key stakeholders);
  • Educational information provided to key stakeholders.
Table
Table 2. Attributes of the 39 OTs delivering ESSVR.
Table 2. Attributes of the 39 OTs delivering ESSVR.
Attribute n (% of Sample)
Gender
Female 35 (90%)
Male 4 (10%)
Job Factors
Clinical Role a
OT 31 (79%)
OT Team Leader 4 (10%)
Therapy Manager 2 (5%)
Independent OT 1 (3%)
Senior Research Assistant 1 (3%)
NHS Band b
Band 6 24 (62%)
Band 7 15 (38%)
ExperienceMean (Standard Deviation)
Years qualified as OT 17.3 (7.95)
Years of experience:
Stroke rehabilitation 9.34 (7.17)
VR 3.55 (4)
Recent research experience
Yes 7 (18%)
No 32 (82%)
Knowledge
Theoretical knowledge of VR
Yes 22 (56%)
No 17 (44%)
Initial Competency Assessment
Needs support 9 (23%)
Competent 28 (72%)
Highly competent 2 (5%)
Engagement with MentoringMean (Standard Deviation)
Total minutes of mentoring received 378.74 (286.38)
Average minutes of mentoring per month 37.77 (25.02)
Abbreviations: NHS: National Health Service; OT: Occupational Therapist; VR: Vocational Rehabilitation. a Job titles of “OT”, “OT Team Leader”, and “Therapy Manager” represent increasing responsibility within the NHS. The one “Independent OT” was working in private practice and was linked to an NHS site for study purposes. The “Senior Research Assistant” was a qualified, practicing OT, but had a clinical research role within their institution. b The NHS band system allocates a point score to each role in the NHS, which determines the basic rate of salary for the role. The higher the band, the more pay and experience associated with the role. The typical entry-level band for OTs is Band 5.
Table
Table 3. Relationship between OT attributes and fidelity assessment score for 39 OTs.
Table 3. Relationship between OT attributes and fidelity assessment score for 39 OTs.
Attributes β95% Confidence Interval p
Lower Upper
Experience
Years qualified as OT 0.28 −0.52 1.07 0.49
Years of stroke rehabilitation experience 0.41 −0.48 1.28 0.36
Years of VR experience −0.29 −1.89 1.31 0.72
Knowledge
Level of education 1.61 −9.34 12.55 0.77
Theoretical knowledge of VR 6.95 −5.55 19.45 0.27
Recent research experience 11.14 −4.86 27.14 0.17
Initial Competence 6.44 −7.00 19.89 0.34
Engagement
Amount of mentoring received pre-fidelity case (minutes) 0.01 −0.01 0.03 0.43
Average monthly amount of mentoring received (minutes) 0.29 0.05 0.53 0.02 *
Abbreviations: OT: Occupational Therapist; VR: Vocational Rehabilitation. * p < 0.05.
Table
Table 4. Relationship between OT attributes and stroke survivor RTW outcomes at 12 months post-randomisation explored by univariate logistic regression.
Table 4. Relationship between OT attributes and stroke survivor RTW outcomes at 12 months post-randomisation explored by univariate logistic regression.
Attributes Odds Ratio 95% Confidence Interval p
Lower Upper
Experience
Years qualified 1.1 1.0 1.2 0.05
Years of stroke rehabilitation experience 1.16 1.02 1.32 0.02 *
Years of VR experience 1.19 0.98 1.45 0.08
Knowledge
Level of education 1.58 0.51 4.92 0.43
Theoretical knowledge of VR 0.82 0.22 3.0 0.76
Recent research experience 0.59 0.1 3.49 0.56
Initial Competence 1.710.91 33.350.06
Engagement
Amount of mentoring received pre-fidelity case (minutes) 1.0 1.0 1.0 0.16
Average monthly amount of mentoring received (minutes) 1.03 1.0 1.07 0.04 *
Fidelity
Fidelity assessment score (%) 1.06 1.01 1.1 0.01 *
Abbreviations: OT: Occupational Therapist; VR: Vocational Rehabilitation. * p < 0.05.
Table
Table 5. Relationship between OT attributes and stroke survivor RTW outcomes at 12 months post-randomisation through univariate logistic regression.
Table 5. Relationship between OT attributes and stroke survivor RTW outcomes at 12 months post-randomisation through univariate logistic regression.
Attributes Odds Ratio 95% Confidence Interval p
Lower Upper
Experience
Years of stroke rehabilitation experience 1.17 1.02 1.35 0.03 *
Fidelity
Fidelity assessment score (%) 1.06 1.01 1.1 0.02 *
* p < 0.05.
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Powers, K.E.; das Nair, R.; Phillips, J.; Farrin, A.; Radford, K.A. Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial. Int. J. Environ. Res. Public Health 2023, 20, 4694. https://doi.org/10.3390/ijerph20064694

AMA Style

Powers KE, das Nair R, Phillips J, Farrin A, Radford KA. Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial. International Journal of Environmental Research and Public Health. 2023; 20(6):4694. https://doi.org/10.3390/ijerph20064694

Chicago/Turabian Style

Powers, Katie E., Roshan das Nair, Julie Phillips, Amanda Farrin, and Kathryn A. Radford. 2023. "Exploring the Association between Individual-Level Attributes and Fidelity to a Vocational Rehabilitation Intervention within a Randomised Controlled Trial" International Journal of Environmental Research and Public Health 20, no. 6: 4694. https://doi.org/10.3390/ijerph20064694

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