Increasing knowledge of best practices in occupational therapists treating post-stroke unilateral spatial neglect

A significant gap exists between evidence-based practice (EBP) and actual occupational therapy (OT) practice in the management of a disabling post-stroke impairment - unilateral spatial neglect (USN). With improved patient outcomes linked to the use of best practices, it is crucial to modify OTs' actual practices in stroke care. To date, no research study has used knowledge translation (KT) to increase knowledge of EBP specific to OTs managing post-stroke USN. The first manuscript of this thesis explores how the "Knowledge to Action Process" model developed by Graham and colleagues, can be used as a step by step guide in creating an effective KT intervention for OTs working in acute stroke care. It describes how previous research has already addressed the "Knowledge Creation" domain of the model through the creation of synthesized materials and knowledge tools. It then goes on to describe how the first two steps of the "Action Cycle" domain have also been addressed; the main problem between EBP and actual practice has been identified and the evidence on best practice USN management has been adapted for acute care. The subsequent two steps that have not yet been addressed include assessing barriers to knowledge use and implementing an intervention. The Knowledge to Action Process model stresses that in order for a KT intervention to be effective in changing clinician practices, the facilitators and barriers faced by clinicians treating a specific clientele, in a specific type of setting, need to be identified.A few studies have assessed the barriers and facilitators to using EBP in rehabilitation; however none are specific to occupational therapists treating post-stroke USN. Thus, the objectives of the second manuscript were twofold: Phase 1) to identify the barriers and facilitators that affect EBP use by acute care OTs treating individuals with post-stroke USN; and Phase 2) to create, to pilot test, to evaluate the feasibility and to conduct preliminary analyses of effectiveness of a multi-modal KT intervention geared towards increasing EBP knowledge acquisition and self-efficacy for USN assessment and treatment. A sub-objective was to conduct preliminary analyses of the association between potential explanatory variables and change in knowledge acquisition and EBP self-efficacy.In the first phase, two focus groups (n=9) were held where acute care OTs treating patients with stroke discussed the barriers and facilitators to EBP use faced in practice. Key barriers included lack of time and basic EBP skills, and lack of personal motivation to change current practices and habits. Key identified facilitators included a multidisciplinary stroke team, recent graduation, and having access to learning material and several educational days annually. In the second phase, a multi-modal USN KT intervention was pilot tested on 20 OTs from Quebec and Ontario. Clinicians took part in an 8 week intervention beginning with a 7 hour in-person USN KT training session. This was followed by an 8 week reinforcement period where they continued their learning online. A pre, pre, post assessment of the main outcome - knowledge of best practices in USN management, was measured online via the Knowledge Questionnaire. The secondary outcome EBP self-efficacy, was assessed using the EBP Self-Efficacy Scale immediately prior to and following the in-person training session. All OTs improved in knowledge of EBP USN management and as a group, a statistically significant improvement was achieved. Similarly, significant improvement was found in clinicians' level of EBP self-efficacy. These results demonstrate that a multi-modal KT intervention based on the Knowledge to Action Process model and identified barriers and facilitators is feasible and effective based on preliminary analysis. However, further investigation of this KT intervention through a randomized control trial is necessary to validate the results on effectiveness obtained in this study.

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