Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study †
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design and Population
2.2. Procedure, Data Collection, and Data Analysis
2.3. Surveys
2.4. Focus Groups
2.5. Analysis
3. Results
3.1. Survey
3.2. Focus Groups
- Being a part of something bigger
- 2.
- Leadership and organizational support
- 3.
- Readiness for change
- 4.
- Delivering the intervention to patients
4. Discussion
Study Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Moore, J.L.; Roth, E.J.; Killian, C.; Hornby, T.G. Locomotor training improves daily stepping activity and gait efficiency in individuals poststroke who have reached a “plateau” in recovery. Stroke 2010, 41, 129–135. [Google Scholar] [CrossRef] [PubMed]
- Lang, C.E.; Macdonald, J.R.; Reisman, D.S.; Boyd, L.; Jacobson Kimberley, T.; Schindler-Ivens, S.M.; Hornby, T.G.; Ross, S.A.; Scheets, P.L. Observation of amounts of movement practice provided during stroke rehabilitation. Arch. Phys. Med. Rehabil. 2009, 90, 1692–1698. [Google Scholar] [CrossRef] [PubMed]
- Wiles, R.; Ashburn, A.; Payne, S.; Murphy, C. Discharge from physiotherapy following stroke: The management of disappointment. Soc. Sci. Med. 2004, 59, 1263–1273. [Google Scholar] [CrossRef] [PubMed]
- Kloda, L.A.; Bartlett, J.C. Clinical information behavior of rehabilitation therapists: A review of the research on occupational therapists, physical therapists, and speech-language pathologists. J. Med. Libr. Assoc. 2009, 97, 194–202. [Google Scholar] [CrossRef] [PubMed]
- Salbach, N.M.; Guilcher, S.J.; Jaglal, S.B.; Davis, D.A. Determinants of research use in clinical decision making among physical therapists providing services post-stroke: A cross-sectional study. Implement. Sci. 2010, 5, 77. [Google Scholar] [CrossRef] [PubMed]
- Ellekjaer, H.; Holmen, J.; Indredavik, B.; Terent, A. Epidemiology of stroke in Innherred, Norway, 1994 to 1996. Incidence and 30-day case-fatality rate. Stroke 1997, 28, 2180–2184. [Google Scholar] [CrossRef] [PubMed]
- Nawaz, B.; Eide, G.E.; Fromm, A.; Øygarden, H.; Sand, K.M.; Thomassen, L.; Næss, H.; Waje-Andreassen, U. Young ischaemic stroke incidence and demographic characteristics–The Norwegian stroke in the young study–A three-generation research program. Eur. Stroke J. 2019, 4, 347–354. [Google Scholar] [CrossRef] [PubMed]
- Gray, C.S.; French, J.M.; Bates, D.; Cartlidge, N.E.; James, O.F.; Venables, G. Motor recovery following acute stroke. Age Ageing 1990, 19, 179–184. [Google Scholar] [CrossRef] [PubMed]
- Patterson, S.L.; Forrester, L.W.; Rodgers, M.M.; Ryan, A.S.; Ivey, F.M.; Sorkin, J.D.; Macko, R.F. Determinants of walking function after stroke: Differences by deficit severity. Arch. Phys. Med. Rehabil. 2007, 88, 115–119. [Google Scholar] [CrossRef] [PubMed]
- Treger, I.; Shames, J.; Giaquinto, S.; Ring, H. Return to work in stroke patients. Disabil. Rehabil. 2007, 29, 1397–1403. [Google Scholar] [CrossRef]
- Vestling, M.; Tufvesson, B.; Iwarsson, S. Indicators for return to work after stroke and the importance of work for subjective well-being and life satisfaction. J. Rehabil. Med. 2003, 35, 127–131. [Google Scholar] [CrossRef] [PubMed]
- Holleran, C.L.; Rodriguez, K.S.; Echauz, A.; Leech, K.A.; Hornby, T.G. Potential contributions of training intensity on locomotor performance in individuals with chronic stroke. J. Neurol. Phys. Ther. 2015, 39, 95–102. [Google Scholar] [CrossRef] [PubMed]
- Holleran, C.L.; Straube, D.D.; Kinnaird, C.R.; Leddy, A.L.; Hornby, T.G. Feasibility and potential efficacy of high-intensity stepping training in variable contexts in subacute and chronic stroke. Neurorehabil Neural Repair. 2014, 28, 643–651. [Google Scholar] [CrossRef] [PubMed]
- Hornby, T.G.; Straube, D.S.; Kinnaird, C.R.; Holleran, C.L.; Echauz, A.J.; Rodriguez, K.S.; Wagner, E.J.; Narducci, E.A. Importance of specificity, amount, and intensity of locomotor training to improve ambulatory function in patients poststroke. Top. Stroke Rehabil. 2011, 18, 293–307. [Google Scholar] [CrossRef] [PubMed]
- Globas, C.; Becker, C.; Cerny, J.; Lam, J.M.; Lindemann, U.; Forrester, L.W.; Macko, R.F.; Luft, A.R. Chronic stroke survivors benefit from high-intensity aerobic treadmill exercise: A randomized control trial. Neurorehabil Neural Repair. 2012, 26, 85–95. [Google Scholar] [CrossRef] [PubMed]
- Macko, R.F.; Ivey, F.M.; Forrester, L.W.; Hanley, D.; Sorkin, J.D.; Katzel, L.I.; Silver, K.H.; Goldberg, A.P. Treadmill exercise rehabilitation improves ambulatory function and cardiovascular fitness in patients with chronic stroke: A randomized, controlled trial. Stroke 2005, 36, 2206–2211. [Google Scholar] [CrossRef] [PubMed]
- Mackay-Lyons, M.; McDonald, A.; Matheson, J.; Eskes, G.; Klus, M.A. Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking ability early after stroke: A randomized controlled trial. Neurorehabil Neural Repair. 2013, 27, 644–653. [Google Scholar] [CrossRef] [PubMed]
- Hornby, T.G.; Rafferty, M.R.; Pinto, D.; French, D.; Jordan, N. Cost-Effectiveness of High-intensity Training vs Conventional Therapy for Individuals with Subacute Stroke. Arch. Phys. Med. Rehabil. 2022, 103, S197–S204. [Google Scholar] [CrossRef] [PubMed]
- Hornby, T.G.; Reisman, D.S.; Ward, I.G.; Scheets, P.L.; Miller, A.; Haddad, D.; Fox, E.J.; Fritz, N.E.; Hawkins, K.; Henderson, C.E.; et al. Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury. J. Neurol. Phys. Ther. 2020, 44, 49–100. [Google Scholar] [CrossRef] [PubMed]
- Moore, J.L.; Nordvik, J.E.; Erichsen, A.; Rosseland, I.; Bo, E.; Hornby, T.G. Implementation of High-Intensity Stepping Training During Inpatient Stroke Rehabilitation Improves Functional Outcomes. Stroke 2020, 51, 563–570. [Google Scholar] [CrossRef] [PubMed]
- Henderson, C.E.; Plawecki, A.; Lucas, E.; Lotter, J.; Scofield, M.E.; Carbone, A.; Jang, J.H.; Hornby, T.G. Increasing the Amount and Intensity of Stepping Training During Inpatient Stroke Rehabilitation Improves Locomotor and Non-Locomotor Outcomes. Neurorehabilit. Neural Repair 2022, 36, 621–632. [Google Scholar] [CrossRef] [PubMed]
- Hornby, T.G.; Holleran, C.L.; Leddy, A.L.; Hennessy, P.; Leech, K.A.; Connolly, M.; Moore, J.L.; Straube, D.; Lovell, L.; Roth, E. Feasibility of Focused Stepping Practice During Inpatient Rehabilitation Poststroke and Potential Contributions to Mobility Outcomes. Neurorehabil. Neural Repair 2015, 29, 923–932. [Google Scholar] [CrossRef] [PubMed]
- Lang, C.; Macdonald, J.; Gnip, C. Counting repetitions: An observational study of outpatient therapy for people with hemiparesis post-stroke. J. Neurol. Phys. Ther. 2007, 31, 3–11. [Google Scholar] [CrossRef] [PubMed]
- MacKay-Lyons, M.J.; Makrides, L. Cardiovascular stress during a contemporary stroke rehabilitation program: Is the intensity adequate to induce a training effect? Arch. Phys. Med. Rehabil. 2002, 83, 1378–1383. [Google Scholar] [CrossRef] [PubMed]
- Fischer, F.; Lange, K.; Klose, K.; Greiner, W.; Kraemer, A. Barriers and strategies in guideline implementation—A scoping review. Healthcare 2016, 4, 36. [Google Scholar] [CrossRef]
- Balis, L.E.; Houghtaling, B. Matching barriers and facilitators to implementation strategies: Recommendations for community settings. Implement. Sci. Commun. 2023, 4, 144. [Google Scholar] [CrossRef] [PubMed]
- Cooper, J.; Murphy, J.; Woods, C.; Van Nassau, F.; McGrath, A.; Callaghan, D.; Carroll, P.; Kelly, P.; Murphy, N.; Murphy, M. Barriers and facilitators to implementing community-based physical activity interventions: A qualitative systematic review. Int. J. Behav. Nutr. Phys. Act. 2021, 18, 118. [Google Scholar] [CrossRef] [PubMed]
- Moore, J.L.; Mbalilaki, J.A.; Graham, I.D. Knowledge Translation in Physical Medicine and Rehabilitation: A Citation Analysis of the Knowledge-to-Action Literature. Arch. Phys. Med. Rehabil. 2022, 103, S256–S275. [Google Scholar] [CrossRef]
- Doyle, L.; Mackay-Lyons, M. Utilization of aerobic exercise in adult neurological rehabilitation by physical therapists in Canada. J. Neurol. Phys. Ther. 2013, 37, 20–26. [Google Scholar] [CrossRef] [PubMed]
- Moore, J.L.; Bø, E.; Erichsen, A.; Rosseland, I.; Halvorsen, J.; Bratlie, H.; Hornby, T.G.; Nordvik, J.E. Development and Results of an Implementation Plan for High-Intensity Gait Training. J. Neurol. Phys. Ther. 2021, 45, 282–291. [Google Scholar] [CrossRef] [PubMed]
- Inness, E.L.; Jagroop, D.; Andreoli, A.; Bayley, M.; Biasin, L.; Danells, C.; Hall, J.; Mansfield, A.; McDonald, A.; Nishri, D.; et al. Factors That Influence the Clinical Implementation of Aerobic Exercise in Stroke Rehabilitation: A Theory-Informed Qualitative Study. Phys. Ther. 2022, 102, pzac014. [Google Scholar] [CrossRef] [PubMed]
- Damschroder, L.J.; Aron, D.C.; Keith, R.E.; Kirsh, S.R.; Alexander, J.A.; Lowery, J.C. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement. Sci. 2009, 4, 50. [Google Scholar] [CrossRef] [PubMed]
- Powell, B.J.; Waltz, T.J.; Chinman, M.J.; Damschroder, L.J.; Smith, J.L.; Matthieu, M.M.; Proctor, E.K.; Kirchner, J.E. A refined compilation of implementation strategies: Results from the Expert Recommendations for Implementing Change (ERIC) project. Implement. Sci. 2015, 10, 21. [Google Scholar] [CrossRef] [PubMed]
- Consolidated Framework for Implementation Resaearch. 2009. Available online: https://cfirguide.org/constructs-old/ (accessed on 7 January 2024).
- Kirk, M.A.; Kelley, C.; Yankey, N.; Birken, S.A.; Abadie, B.; Damschroder, L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement. Sci. 2016, 11, 72. [Google Scholar] [CrossRef] [PubMed]
- Robinson, C.H.; Damschroder, L.J. A pragmatic context assessment tool (pCAT): Using a Think Aloud method to develop an assessment of contextual barriers to change. Implement. Sci. Commun. 2023, 4, 3. [Google Scholar] [CrossRef] [PubMed]
- CFIR Interview Guide Tool. Available online: https://cfirguide.org/guide/app/#/ (accessed on 6 January 2024).
- Hsieh, H.F.; Shannon, S.E. Three approaches to qualitative content analysis. Qual. Health Res. 2005, 15, 1277–1288. [Google Scholar] [CrossRef] [PubMed]
- Van den Broeck, A.; Howard, J.L.; Van Vaerenbergh, Y.; Leroy, H.; Gagné, M. Beyond intrinsic and extrinsic motivation: A meta-analysis on self-determination theory’s multidimensional conceptualization of work motivation. Organ. Psychol. Rev. 2021, 11, 240–273. [Google Scholar] [CrossRef]
- Deci, E.L.; Ryan, R.M. Intrinsic Motivation and Self-Determination in Human Behavior; Springer: New York, NY, USA, 1985. [Google Scholar]
- Van den Broeck, A.; Ferris, D.L.; Chang, C.-H.; Rosen, C.C. A Review of Self-Determination Theory’s Basic Psychological Needs at Work. J. Manag. 2016, 42, 1195–1229. [Google Scholar] [CrossRef]
- Moore, J.L.; Bjørkli, C.; Havdahl, R.T.; Lømo, L.L.; Midthaug, M.; Skjuve, M.; Klokkerud, M.; Nordvik, J.E. A qualitative study exploring contributors to the success of a community of practice in rehabilitation. BMC Med. Educ. 2021, 21, 282. [Google Scholar] [CrossRef] [PubMed]
- Harrison, M.; Graham, I.D. Knowledge Translation in Nursing and Healthcare: A Roadmap to Evidence-Informed Practice, 1st ed; Wiley-Blackwell: Hoboken, NJ, USA, 2021. [Google Scholar]
- Kothari, A.; McCutcheon, C.; Graham, I.D. Defining Integrated Knowledge Translation and Moving Forward: A Response to Recent Commentaries. Int. J. Health Policy Manag. 2017, 6, 299–300. [Google Scholar] [CrossRef] [PubMed]
- Gagliardi, A.R.; Berta, W.; Kothari, A.; Boyko, J.; Urquhart, R. Integrated knowledge translation (IKT) in health care: A scoping review. Implement. Sci. 2016, 11, 38. [Google Scholar] [CrossRef] [PubMed]
- Gainforth, H.L.; Hoekstra, F.; McKay, R.; McBride, C.B.; Sweet, S.N.; Martin Ginis, K.A.; Anderson, K.; Chernesky, J.; Clarke, T.; Forwell, S.; et al. Integrated Knowledge Translation Guiding Principles for Conducting and Disseminating Spinal Cord Injury Research in Partnership. Arch. Phys. Med. Rehabil. 2021, 102, 656–663. [Google Scholar] [CrossRef] [PubMed]
- Gagné, M.; Parker, S.K.; Griffin, M.A.; Dunlop, P.D.; Knight, C.; Klonek, F.E.; Parent-Rocheleau, X. Understanding and shaping the future of work with self-determination theory. Nat. Rev. Psychol. 2022, 1, 378–392. [Google Scholar] [CrossRef] [PubMed]
- Chamberlain, P.; Brown, C.H.; Saldana, L. Observational measure of implementation progress in community based settings: The stages of implementation completion (SIC). Implement. Sci. 2011, 6, 116. [Google Scholar] [CrossRef] [PubMed]
- Alley, Z.M.; Chapman, J.E.; Schaper, H.; Saldana, L. The relative value of Pre-Implementation stages for successful implementation of evidence-informed programs. Implement. Sci. 2023, 18, 30. [Google Scholar] [CrossRef] [PubMed]
- Butzer, J.F.; Virva, R.; Lenca, L. Commentary on the Challenges and Benefits of Implementing Standardized Outcome Measures. Arch. Phys. Med. Rehabil. 2022, 103, s246–s251. [Google Scholar] [CrossRef] [PubMed]
- Romney, W.M.; Wormley, M.E.; Veneri, D.; Oberlander, A.; Catizone, V.; Grevelding, P. Physical and occupational therapists’ perceptions of sustainability of a knowledge translation intervention to improve the use of outcome measures in inpatient rehabilitation: A qualitative study. Qual. Life Res. 2023, 33, 653–665. [Google Scholar] [CrossRef] [PubMed]
- Sørensen, K. Defining Health Literacy: Exploring Differences and Commonalities; Policy Press: Bristol, UK, 2019. [Google Scholar]
- Roundtable on Health Literacy; Board on Population Health and Public Health Practice; Institute of Medicine. Implications of Health Literacy for Public Health: Workshop Summary; National Academies Press: Washington, DC, USA, 2014. [Google Scholar] [CrossRef]
- Damschroder, L.J.; Reardon, C.M.; Widerquist MA, O.; Lowery, J. The updated Consolidated Framework for Implementation Research based on user feedback. Implement. Sci. 2022, 17, 75. [Google Scholar] [CrossRef] [PubMed]
Characteristics of the Clinicians | ||||
---|---|---|---|---|
Variables | Facility 1 | Facility 2 | Facility 3 | Total |
Sex | ||||
Female | 4 | 3 | 2 | 9 |
Male | 1 | 2 | 1 | 4 |
Age (years) | ||||
20–29 | 1 | 1 | 2 | |
30–39 | 3 | 1 | 4 | |
>40 | 1 | 4 | 2 | 7 |
Work experience (years) | ||||
<5 | 2 | 1 | 3 | |
5–10 | 3 | 3 | ||
11–15 | 1 | 1 | ||
>15 | 3 | 3 | 6 | |
Approximate stroke patients seen in a week per clinician | ||||
>10 patients | ||||
5–9 patients | 2 | 2 | 1 | 5 |
1–4 patients | 3 | 3 | 2 | 8 |
<1 patients | ||||
Approximate number of stroke patients treated with HIT per week | ||||
>10 patients | ||||
5–9 patients | 2 | 1 | 3 | |
1–4 patients | 2 | 3 | 3 | 8 |
<1 patient | 1 | 1 | 2 | |
Experience with providing HIT | ||||
Beginner | 3 | 2 | 2 | 7 |
Average | 2 | 2 | 1 | 5 |
Expert | 1 | 1 | ||
Employment Setting | ||||
Hospital | 5 | 5 | ||
Private rehabilitation institute | 3 | 3 | ||
Municipality | 5 | 5 | ||
Profession | ||||
Physiotherapist | 4 | 3 | 3 | 11 |
Occupational therapist | 1 | 1 | ||
Sport therapist | 2 | 2 | ||
Number of Patients with Stroke per Year | ||||
Facility 1 | Facility 2 | Facility 3 | ||
Approximate number of patients with stroke per year | 70 | 120 | 105 |
Barriers with a Strong Effect | Barrier with a Weak Effect | Neutral | Facilitator with a Strong Effect | Facilitator with a Weak Effect | Mixed Responses | |
---|---|---|---|---|---|---|
1. People here regularly seek to understand the needs of patients and make changes to better meet those needs. Patient Needs and Resources | F 1 F 2 | F 3 | ||||
2. I have open lines of communication with everyone needed to make the change. Networks and Communications | F 2 | F 1 F 3 | ||||
3. I have access to data to help track changes in outcomes. Goals and Feedback (or Reflecting and Evaluating depending on context/phase) | F 2 | F 1 | F 3 | |||
4. The implementation of high-intensity gait training is aligned with leadership goals. Relative Priority | F 2 | F 1 F 3 | ||||
5. The implementation of high-intensity gait training competes with other projects that require resources in my facility. Relative Priority | F 1 F 3 | F 2 | ||||
6. The implementation of high-intensity gait training is aligned with clinician values. Compatibility | F 2 | F 1 F 3 | ||||
7. The implementation of high-intensity gait training is compatible with existing clinical processes. Compatibility | F 1 F 3 | F 2 | ||||
8. The structures and policies in place here enable us to successfully implement high-intensity gait training. Compatibility; Structural characteristics | F 1 F 3 | F 2 | ||||
9. We have sufficient space to implement high-intensity gait training. Available Resources | F 1 F 3 | F 2 | ||||
10. We have sufficient time dedicated to implement high-intensity gait training. Available Resources | F 1 F 3 | F 2 | ||||
11. We have other needed resources to implement high-intensity gait training (staff, money, supplies, etc.). Available Resources | F 3 | F 1 F 2 | ||||
12. People here see the current situation (i.e., usual care) as intolerable and that the change is needed. Tension for Change | F 2 F 3 | F 1 | ||||
13. People here see the advantage of implementing high-intensity gait training versus an alternative change. Relative Advantage | F 2 F 3 | F 1 | ||||
14. Higher level leaders are committed, involved, and accountable for implementation of high-intensity gait training. Leadership Engagement | F 1 F 3 | F 2 | ||||
15. Leaders I work with most closely are committed, involved, and accountable for the implementation of high-intensity gait training. Leadership Engagement | F 1 F 3 | F 2 | ||||
16. The high-intensity gait intervention can be implemented in a way that meets my patient’s needs. Adaptability | F 1 F 2 | F 3 | ||||
17. The high-intensity gait intervention can easily be implemented in my own practice. Complexity | F 3 | F 1 F 2 | ||||
18. I have the resources and materials that I need to successfully implement high-intensity gait training. Design Quality and Packaging | F 1 F 3 | F 2 | ||||
19. High-intensity gait training is considered an important intervention to implement by the health services (i.e., payers). Peer pressure, external policies and incentives | F 1 F 3 | F 1 F 2 | ||||
20. The culture of my organization will support the implementation of high-intensity gait training. Culture | F 3 | F 1 | F 2 | |||
21. I have access to the training and mentoring that I need to successfully implement high-intensity gait training. Access to knowledge and information | F 1 F 2 F 3 | |||||
22. I am confident that I will be able to successfully use high-intensity gait training with my patients. Self-efficacy | F 2 F 3 | F 1 | ||||
23. Clear implementation goals for high-intensity gait training have been identified. Reflecting and evaluating | F 1 | F 3 | F 2 | |||
24. Clinicians and leaders who will champion and lead this change have been identified in my department. Opinion leaders, formally appointed internal implementation leaders, and champions | F 2 F 3 | F 1 | ||||
25. I believe high-intensity gait training will result in better patient outcomes than my usual care interventions. Knowledge and Beliefs about the Intervention | F 1 F 2 F 3 |
(a) Consolidated Framework for Implementation Research (CFIR) Domain—Innovation Characteristics | ||
Construct–Impact | Description | Quotes |
Innovation Source—Barrier(s) | Not offered a choice to participate in the project | It is just as if it has been thrown at us, this project, that we should be involved in it. F2-P4 (−) |
Strength and Quality—Facilitator(s) | Aware of evidence that supports the intervention | I think about all that good research behind this, you know, that it works; it has been researched on, so you can be confident. F1-FP5 (+) I think that’s very good, and it’s systematized so you know it works, that there are research showing that it is effective, being able to tell them this, that’s good, I think. F3-P2 (+) |
Relative Advantage—Facilitator(s) | Patient and caregivers’ desire to perform HIT | Both relatives and the patients ask to be referred for more rounds of the same treatment. F1-P1 (+) |
Clinicians’ observations of impact of HIT on patients | Yes, they become more quickly independent in walking, and they get increased walking distance and walking quality. Many of them also gets better balance more quickly. F2-P5 (+) All the patients I have worked with are so positive, and it seems like they also get a psychological boost from the training. Exercising with high intensity, and then you get that in addition. F2-P5 (+) | |
Belief the work to use HIT is worth the effort | Even though this is complex, the trade-off is worth it. F3-P2 (+) | |
Relative Advantage—Barrier(s) | Costs related to delivering, considering patient volume | To invest is a very large investment for a small institute. So far, I have not had enough patients for it to be defendable/justifiable/proper… In terms of resources, you could say that it is a barrier there. F1-P3 (−) |
Adaptability—Facilitator(s) | HIT can use commonly available equipment | I do think it is important to tell both the patient and next therapist that it doesn’t have to be so complicated. As you said, you don’t need a treadmill, you can do a whole lot only using a stairway, walking outside, walking inside, finding some obstacles, it does not have to be expensive. There are some things you do need, to ensure safety, but anyway, there are several things you can do that is so much closer to HIT than what has been done in the past using inexpensive stuff, but you have to have the knowledge. F3-P3 (+) |
Adaptability—Barrier(s) | Scheduling HIT sessions | And then it is about the time, we can count the minutes used on a “[HIT]” patient, and maybe we use fifteen minutes more than on a patient not included in the “[HIT]” project, but you can’t just put them in anywhere in your calendar, because you can’t do high-intensity gait training right after the patients breakfast, and maybe they have to have patient education with the doctor or other things they have to do, so we have to make sure that they get some rest both before and after, that’s also a barrier. F3-P2 (−) |
Complexity—Barrier(s) | Many tasks required in HIT protocol | Starting to follow protocols on measuring blood pressure, (…) all the things you do not have to do when carrying out a training session to know how the patient are doing, how is the blood pressure, as we are told to have an eye on…, it’s been difficult for people to do all this. F2-P5 (−) |
Requirements for achieving fidelity | I think it is a barrier with some of the patients when I’m not able to increase their pulse above 75%, and you have to have them there for 40% to be able to call it “[HIT]”, and it’s supposed to be like this for so and so long. It has also been a barrier that, everyone should have one-hour treatment, and you cannot be doing anything else. F3-P2 (−) | |
Design Quality and Packaging—Facilitator(s) | In-person workshop on HIT | It was something else being at [the course] this time. It was exciting to see how they pushed, because I got a much better impression being there, than looking upon it theoretically or having online discussions. F1-P2(+) |
Accessibility of knowledge and variability in educational content | Especially, also because they [clinicians trained in HIT] have a kind of buffet (…). You get very concrete examples. Even if you only see it on video, that’s one thing, but when you are in the room and watching it, that enriches the range of what you see. F1-P5 (+) | |
Continuous access to educational information in Norwegian | All the courses we have gone through are available for us every day. Therefore, we can look on them, and we have graphs that clearly shows us that if this is the barrier, we can try this intervention (…). Now everything that was previously only in English is also in Norwegian, and the coursers and the graphs and everything is there, so it is possible to obtain knowledge. F2-P5 (+) | |
(b) CFIR Domain—Outer Setting | ||
Construct–Impact | Description | Quotes |
Needs and Resources of Those Served by the Organization—Barrier(s) | Patients’ health and fitness status | Many of them have chronic ailments, sort of, and are thereby deconditioned compared to if they were admitted directly after this happened, they might have had better fitness condition. They have pretty low fitness capacity, the ones we meet. F1-P2 (−) |
Side effects of exercise | We experienced, now recently, with the last patient I have worked with lately, that he complained about hip pain on his healthy side, hip and knee maybe. They are worn out there. F2-P2 (−) | |
Patients’ ability to understand information about HIT | Some people need a simpler explanation than others do who may want a bit more detail to get a deeper understanding. F3-P2 (−) | |
Needs and Resources of Those Served by the Organization—Facilitator(s) | Observation of positive impact of HIT on patients. | All the patients I have worked with are so positive, and it seems like they also get a psychological boost from the training. Exercising with high intensity, and then you get that in addition. F2-P5 (+) |
Cosmopolitanism—Facilitator(s) | Good peer collaboration and mentoring | It is great that if we have any questions, they [other clinicians trained in HIT] are there for us. After all, they are more experienced than we are. In addition, there are so many issues along the way in the process, which are not easy to handle alone. That is why it is nice that someone is there to ask. They are so eager to help. F1-P1 (+) |
Participating in a project with other institutions and identifying role models | It is also good to know there is other institutions doing the same as us, so that we are not all [alone]…, yes. And that there is someone like [other facility that successfully implemented HIT], further ahead and, that we have something to aim for and get better. F2-P2 (+) | |
Gaining a positive reputation in the professional community by participating | One thing is the formality, but the physiotherapy community in Norway is not that big, so the word will go around about what we are doing here, and this will influence positive on our reputation. F3- P2 (+) | |
Being a part of a community that is advancing a profession | I do not think it is the project alone, but a combination of things. But being a part of a professional community that influence progress, and this community, and being a part of a project that gives us a professional community, that has been extremely important, because we actually have…, I’m sure we have recruited a lot of patients that way. F3-P3 (+) | |
Receiving patient referrals because the facility is delivering HIT | Yes, we are working to get information out about the offer we have, constantly/continuously. We have had some [public relations] rounds in the past, where we have travelled around in some places and talked/informed to the people about our offer. It has been a few years now since we did that, because of the pandemic. However, we have also given information to/informed municipalities and [general practitioners], for example here in the area. It is also important to spread the information about our offer in member’s magazines, for example in Stroke and Aphasia and the [National Association for Heart and Lung Disorders]. I know we have had more referrals/inquiries because people have read about it, or the rumors have spread. F3-P3 (+) | |
Peer pressure—Facilitator(s) | Learning about others who successfully implemented HIT | I remember that we were at that rehabilitation conference in Kristiansand, when [clinicians from a facility that implemented HIT] presented this for the first time, maybe, so it must be 5 or 6 years ago. F2-P3 (+) |
Belief that HIT should be delivered to “keep up” in the field | But then I remember us talking to [an advisor] in a meeting, that if we were to be in the ball game with everything going on in rehabilitation and stroke rehabilitation, we can’t say no to this. F2-P2 (+) | |
Gaining a positive reputation because of delivering HIT | One thing is the formality, but the physiotherapy community in Norway is not that big, so the word will go around about what we are doing here, and this will influence positive on our reputation. F3-P2 (+) | |
Belief that delivering HIT will help secure future contracts in the health system | Since we are a private rehabilitation centre, we are not a competitor to [other hospitals implementing HIT], but I do want to say that high-intensity gait training is an absolute advantage for us. F3-P3 (+) However, we cannot stop here you know, because it will be a continuous process forward, and we know that sooner or later there will be another contract competition. Then we can highlight that we can offer this intervention, and if this is the trend in the society, or if more people get their eyes open to the fact that this is important, I do think that this can be crucial whether we will be able to keep contract or not. F3-P3 (+) | |
External Policy and Incentives—Facilitator(s) | Belief that delivering HIT will help secure future contracts in the health system | We have a contract to bear in mind, and that’s kind of a barrier, and also maybe a facilitator since we have to move on because we don’t have time to wait, but that might also be a barrier because it limits our opportunities. F3-P3 (+) |
Belief that offering HIT may influence others to refer patients to the facility | Both in terms of winning future contracts (with the health authorities), but also when it comes to recruiting patients from the hospitals, because if they know that we offer good treatment, they will recommend us to their patients, and it is these recommendations that will influence where the patients will decide to go for rehabilitation after discharged from the emergency department in the large hospitals in Oslo, where from we usually receive patients. F3-P3 (+) | |
(c) CFIR Domain—Inner Setting | ||
Construct–Impact | Description | Quotes |
Structural Characteristics—Barrier(s) | Competing priorities related to patients and work responsibilities | It has been a barrier, the way we are organised, because we have other patient groups we must alternate, and we have responsibilities that makes it impossible to follow up on everything we are supposed to do and prioritise. F2-P5 (−) |
Networks and Communications—Facilitator(s) | Importance of open communication and collaboration | I experience an open dialogue, but sometimes we disagree. I think it’s important to be open for discussion if you aren’t certain. Between those I work closest with, I mean we have an open climate. F1-P2 (+) I think it is important to have a professional environment around, so that you can discuss certain cases. F1-P2 (+) |
Other professional involvement and effect of HIT on different body functions | Therefore, it is fun when we have engaged neuropsychologists who also come up with things in relation to plasticity in the brain and heart rate increase. Is not it, it has an effect on more things than (indistinct) then, that is, in relation to physical health, cognition not least. Therefore, it is a bit of a win-win on several levels, it is not just another function. Moreover, I think we have a lot of support in several professional groups, with some significance in that sense. F2-P3 (+) | |
Networks and Communications—Barrier(s) | Lack of patients | We have had quite few stroke patients for a while, so we don’t get stroke patients to work with [doing HIT], it is almost a dispute over who gets the patient, so you almost don’t have any [inaudible] patients, and then you lose ownership to the project for a while. F2-P4 (−) |
Lack of information, engagement, and feeling excluded | I do feel that we sometimes aren’t that included, a lot of information never reaches us, and due to this I stop following and loses my engagement (…). We do not get enough information, we don’t have any papers, we don’t have sufficient experience. And then we are all asked to go through this and this. Therefore, sometimes, I do feel a little bit on the side of the project, from my point of view. This might be some criticism, but it is a little bit like that. F2-P4 (−) | |
Culture—Facilitator(s) | Strong group support and collaboration | I think it is nice to be a group; we are 3–4 working together all the time. We bring out the best in each other and challenge each other regarding any questions we might have. I do think, going through this all alone would have been tough. The fact that we are a group, and… F3-P1 (+) |
Implementation Climate, Compatibility—Barrier(s) | Negative comments from colleagues | One thing that came to my mind—when I meet, colleagues who do not work on my team, in the stairs, they might say, “you push them too hard”, and that might almost be a barrier. F3-P3 (−) |
Implementation Climate, Goals and Feedback—Facilitator(s) | Leaders’ expectation on innovation | It is a clear expectation in this organisation, that this is what we want to do, if they (the patients) have had a stroke and wants to be better at walking, we shall always consider this to the be the best intervention. It’s a clear expectation from the management that this is what we are going to do. F1-P2 (+) |
Implementation Climate, Goals and Feedback—Barrier(s) | Lack of implementation goal | I do not think we have a goal for it in the institute other than that we should use it as much as possible when we see that it is the right measure/intervention. F1-P1 (−) |
Implementation Climate, Learning Climate—Facilitator(s) | Openness to trying new things | I have the same impression, that we are very open to try new things. Always onto new research and interventions. F1-P4(+) |
Open communication | I experience an open dialogue, but sometimes we disagree. I think it’s important to be open for discussion if you aren’t certain. Between those I work closest with, I mean we have an open climate. F1-P2 (+) | |
Group consensus to implement | Also, everyone is reasonably agreed on that this is a good thing; this is what we should do. None of us healthcare professionals are resisting this change. F 2-P1 (+) | |
Implementation Climate, Learning Climate—Mixed | Criticism from colleagues | However, it can actually be a barrier if you experience critical glances from colleagues. It could be positive, it could be praise, you are really good, but it could also simply be that they are actually a little critical of the fact that they hear their breath go away. F3-P3 (X) One thing that came to my mind—when I meet, colleagues from my team in the stairs, they might say, “you push them too hard”, and that might almost be a barrier. F3-P3 (−) |
Readiness for Implementation, Leadership Engagement—Facilitator(s) | Leader support | Our managers have been very supportive of us going to [other facilities] for follow-up and such, so it has been arranged from the top of the organization to go there. F1-P1 (+) Time is a barrier, but it doesn’t feel like a problem, but it could have been, if we didn’t have support from the management, or if we weren’t motivated, for example. F3-P2 (+) I think that an important facilitator is the support we have from the management and the head of the physiotherapists. F3-P1 (+) I do think that the job [the team leader] has done, we do have to boast about the team leader for the stroke team, who has worked a lot to get routines and procedures in place, everything from forms and contact with [the external facilitator], and it would not have gone as well without [the team leader]. F3-P2 (+) In addition, [the team leader] just carries on, if there is a small problem that needs to be solved, we experience that this is prioritised. Now, this is what we do and focus on, so that is a facilitator to solve any barrier that may arise, actually. F3-P2 (+) |
Readiness for Implementation, Leadership Engagement—Barrier(s) | Lack of leadership support and engagement | The management has been supportive, but our leader is not… is not enough involved professionally, she has just run over us, you know. F2-P5 (−) |
Was not provided with choice to participate. | It’s just like it’s been thrown at us, this project, that we should be involved in it. F2-P4 (−) | |
Readiness for Implementation, Available Resources—Facilitator(s) | Availability of the equipment | Therefore, that is also something we found we had to find a solution for it. It. Also, that all the equipment, now we have shelves so that they are close to where we are in the training hall, that the equipment is easily accessible. That we have more braces. F3-P3 (+) |
Assistance in compiling the data | Mostly, we talk about facilitators, but having control of all the data we collect—that is a barrier, but we do have a great facilitator in [the researcher]. He has full control of the statistical programs and plots all the data, so we do not have to spend any time on that ourselves. We register on paper when we finish the patient and then we review it, and give it to [the researcher], who plots it. F 3-P3 (+) And then we have [the researcher] who takes care of the data, it’s great, we just hand it over to him and he plots and do all the work connected to that, so we don’t have to do this ourselves. F3-P1 (+) We do the practical thing, but [the researcher] plots a thousand numbers/figures on each patient. F3-P3 (+) | |
Readiness for Implementation, Available Resources—Barrier(s) | Lack of therapists on staff | We do not always feel that we have enough resources, regarding therapists. F1-P3 (−) |
Lack of the patients and equipment | To invest is a very large investment for a small institute So far, I have not had enough patients for it to be defendable/justifiable/proper… In terms of resources, you could say that it is a barrier there. F1-P5 (−) | |
Readiness for Implementation, Access to Knowledge and Information—Facilitator(s) | Attending in-person workshop | It was something else being at [a facilitate that implemented HIT] this time. It was exciting to see how they pushed, because I got a much better impression being there, than looking upon it theoretically or having online discussions. F1-P2 (+) |
Access to and variability in education resources | Especially, also because they [colleagues trained in HIT] have a kind of buffet (…). You get very concrete examples. Even if you only see it on video, that’s one thing, but when you are in the room and watching it, that enriches the range of what you see. F2-P3 (+) | |
Taking educational course as a group | Another thing you mentioned as a barrier, regarding knowledge, that was a barrier for us in the beginning, I would say, but then we joined the gait course on the “knowledge translation” page, which we worked on rather systematically, both individually and as a group. My opinion is that this has been a great course, which has given us the confidence we maybe needed to know what to do, and with a specific focus on which subcomponents the patient needs to practice on, how to balance both the intensity and the number of repetitions ad the focus on subcomponents, I feel that this has been an extremely important course, giving us the right foundation, even though we still are in the beginning of this. F3-P3 (+) | |
Readiness for Implementation, Access to Knowledge and Information—Barrier(s) | Education in different language, Lack of ability to practice HIT after education | It was quite intensive, and in English, and it has been a while, and when there is a period in between when you haven’t been at work and working with intensive gait training, for me, the knowledge seems to fade a little bit. F2-P1(−) |
(d) CFIR Domain—Characteristics of Individuals | ||
Construct–Impact | Description | Quotes |
Knowledge and Beliefs about the Innovation—Facilitator(s) | Belief in the intervention Confidence in delivering HIT and communicating with colleagues | I really do believe in this. It is really a great way to exercise. F3-P1(+) I have more much more faith in that. I also believe that you should train them with high intensity and heart rate. It’s somewhat like heart training, you combine those two. F3-P1 (+) We have become familiar with which intensity zones the patients have had during the session and it has gone well. Thereby you are able to say something about where their normal pulse is and then maybe the physiotherapist back home also will be more confident that this way of exercising is possible to carry out. F3-P2 (+) |
Knowledge and Beliefs about the Innovation—Barrier(s) | Explaining the intervention in an understandable manner | Moreover, maybe some people need a simpler explanation than others do who may want a bit more detail to get a deeper understanding. F3-P2 (−) |
Conflicting beliefs about clinical practice | The oldest (physiotherapists) working here said that they were glad they should retire because this was completely against all the physiotherapy they have learned. That I remember! F2-P4 (−) Sometimes I do think we have too much focus on whether we should do this or that, instead of just doing it. I wish that we in the beginning just started practising high intensity and more steps, and then figuring out the details along the way. F2-P4 (−) | |
Self-efficacy—Barrier(s) | Lack of confidence | I also think lack of confidence might be a barrier. I think that several of us still feel a little inexperienced and needing more, maybe take up again weekly cases, and maybe follow one another to learn more. F2-P2 (−) |
Individual Stage of Change—Facilitator(s) | Openness to change | I do feel that all of us, who are working here, are willing to change. F1-P3 (+) |
Highly motivated clinicians working as a team | I do experience that all of us is highly motivated for this, and if we had not been, it would have been difficult to pull through, because it has been necessary to use the little gaps in the timetable, and to bring stuff home and work on it over time. F3-P2 (+) | |
Individual Stage of Change—Barrier(s) | Physical workload for the physical therapist | What I do know, is that I’m not always that committed, and I also have some bad knees, and it’s not so great when we don’t function that well, then it’s hard to contribute, sometimes I just have to pay attention to this and transfer them (the patients), depending on how my joints are, and that’s just the way it is. F2-P4 (−) |
(e) CFIR Domain—Process | ||
Construct–Impact | Description | Quotes |
Planning—Barrier(s) | Lack of planning | I feel that this has been thrown onto us without a sufficient plan, and it was a lot… After every meeting, there were new things, and suddenly there was a lot of things we had to take care of. What we are doing now is balanced and calm, but the path here has been long and messy, I think. F2-P4 (−) |
Engaging, Formally Appointed Implementation Leaders—Facilitator(s) | Leadership support | Likewise, I think the work [the team leader] has done, we should be allowed to brag/boast/highlight about as a stroke team leader and has worked a lot to put routines and procedures in place here. Everything from forms and the contact with [the external facilitator], it would not go very well in the same way at all, without [the team leader]. F3-P2 (+) In addition, [the team leader] just intensified/drives on, if it’s a small matter that needs to be resolved, we feel that we have always put it here/on the table first. Now this is what we are working on, and that is what we are focusing on, so it will be a facilitator for to solve any barriers that may arise in fact. F3 P2 (+) |
Engaging, Formally Appointed Implementation Leaders—Barrier(s) | Lack of patients and poor distribution of patients | I think [the opinion leader] had many [patients], it is not unnatural, I do not disagree with that, but it means that the rest of us have lost some ownership in it. F1-P3 (−) |
Engaging, External Change Agents—Facilitator(s) | Referrals for high-intensity gait training | After all, we receive relatively/quite few inquiries from [general practitioners] about high-intensity gait training, so it is rather the other way around. The doctors who have heard about high-intensity gait training are the ones who have received an e-link from us that is it enough. F1- P2 (+) |
Engaging, External Change Agents—Innovation Participants, Facilitator(s) | Patients enjoy HIT | There are also patients that really like being out of breath; they might not have been in a long time, being really worn out. Also, in other settings than gait training, they become really worn out. That is positive. F2-P1 (+) |
Motivation from test results | They rather see that progress in the tests; they become more motivated to make an effort even more. F2-P3 (+) | |
Engaging, External Change Agents—Innovation Participants, Barrier(s) | Patients lack understanding about the intervention | The patients are often not prepared for how much effort is required for them to achieve the intensity and the frequency you mentioned earlier. A lot of them take for granted that there will be more breaks along the way, which they should be less active. They get tired, starts complaining; want to stop before we actually are done. F1-P4 (−) Optimism on their own behalf maybe [patients], overestimating their own capacity, or they hear what you say, but in their own translation, they might think that it probably is not that heavy. There is a lot left to interpretation, so you can be as clear as you like, without this necessarily being perceived the same way. F1-P1 (−) Ok, they have gotten information, but they might not have understood this information well enough. We give them expectations that we will keep going for so and so long, so when they start exercising, it becomes too much, sort of, they do not have any experience on how exhausting it is. F1-P4 (−) |
Conflicting information that patients received about the content of physical therapy | And some [patients], they swallow it all, sort of, they don’t need that much explanation, but just do as we…, but others are more critical and yes: “but my physiotherapist back home are stretching and such (…).” And then we are saying that: “now we are doing it this way”. To convey new knowledge to the patient. F3-P3 (−) | |
Executing—Barrier(s) | Lack of focus during implementation | It has been a challenge regarding that it has been a little too much back and forth, I totally agree that we have lost track now and then. How to get back on track, and eventually we have. F2-P5 (−) |
Lack of commitment, information, and treatment fidelity | There have been some challenges with implementation, getting everyone equally committed, having enough information about the project, and pushing the patients hard enough to actually do what they are supposed to do. F2-P5 (−) |
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content. |
© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
Share and Cite
Mbalilaki, J.A.; Lilleheie, I.; Rimehaug, S.A.; Tveitan, S.N.; Linnestad, A.-M.; Krøll, P.; Lundberg, S.; Molle, M.; Moore, J.L. Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study. J. Clin. Med. 2024, 13, 3708. https://doi.org/10.3390/jcm13133708
Mbalilaki JA, Lilleheie I, Rimehaug SA, Tveitan SN, Linnestad A-M, Krøll P, Lundberg S, Molle M, Moore JL. Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study. Journal of Clinical Medicine. 2024; 13(13):3708. https://doi.org/10.3390/jcm13133708
Chicago/Turabian StyleMbalilaki, Julia Aneth, Ingvild Lilleheie, Stein A. Rimehaug, Siri N. Tveitan, Anne-Margrethe Linnestad, Pia Krøll, Simen Lundberg, Marianne Molle, and Jennifer L. Moore. 2024. "Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study" Journal of Clinical Medicine 13, no. 13: 3708. https://doi.org/10.3390/jcm13133708
APA StyleMbalilaki, J. A., Lilleheie, I., Rimehaug, S. A., Tveitan, S. N., Linnestad, A.-M., Krøll, P., Lundberg, S., Molle, M., & Moore, J. L. (2024). Facilitators and Barriers to Implementing High-Intensity Gait Training in Inpatient Stroke Rehabilitation: A Mixed-Methods Study. Journal of Clinical Medicine, 13(13), 3708. https://doi.org/10.3390/jcm13133708