Feasibility and Effect of a Professional Education Workshop for Occupational Therapists’ Management of Upper-Limb Poststroke Sensory Impairment

Susan D. Doyle; Sally Bennett

doi:10.5014/ajot.2014.009019

Abstract

OBJECTIVE. We examined the development, implementation, and effectiveness of a theory-based workshop to facilitate knowledge translation for occupational therapists addressing upper-limb poststroke sensory impairments.

METHOD. Nineteen therapists participated in a quasi-experimental pretest–posttest study that included an 8-hr evidence-based workshop designed using the Theory of Planned Behavior. We measured changes in knowledge, attitudes, and perceived behavioral control and intended behaviors regarding sensory impairment management, research utilization, and shared decision making.

RESULTS. We noted significant changes in knowledge, attitudes, and perceived behavioral control and intended behaviors about sensory impairment management, research utilization, and shared decision making and made recommendations for changes in recruitment strategies, outcome measures, and workshop content.

CONCLUSION. A theory-based workshop can potentially affect knowledge, attitudes, and intended behaviors about sensory impairment management, research utilization, and shared decision making. A randomized controlled trial evaluating this intervention is warranted and will potentially improve understanding of methods to facilitate knowledge translation.

The incidence of stroke survivors with upper-limb poststroke sensory impairments (ULPSSI) varies between 53% and 89%, depending on the sensory modality tested and methodology used (Acerra, 2007; Yekutiel, 2000). Comparatively little research attention has been focused on ULPSSI (somatic senses such as touch, temperature, pain, and proprioception) despite its being associated with decreased safety, motor quality, and spontaneous upper-limb use and reduction in functional levels and long-term participation (Tyson, Hanley, Chillala, Selley, & Tallis, 2008; Yekutiel, 2000).

Evidence for the effectiveness of ULPSSI interventions is growing (Doyle, Bennett, Fasoli, & McKenna, 2010), and evidence from well-powered studies (Acerra, 2007; Carey, Macdonell, & Matyas, 2011) suggests benefits from remediation approaches incorporating grading and feedback and principles of retraining. However, this evidence may not be routinely used in practice. A recent survey of 145 U.S. occupational therapists who treat stroke survivors (Doyle, Bennett, & Gustafsson, 2013) found that 46% provided ULPSSI interventions only half of the time or less when treating stroke survivors. Only 12.5% of the reported interventions for ULPSSI included sensory reeducation (graded interventions using reeducation principles). Half of the respondents reported lack of knowledge and skills as a barrier to addressing ULPSSI, and 78.2% reported that their knowledge of ULPSSI was not up to date and identified a need for information and training in ULPSSI management (Doyle, Bennett, & Gustafsson, 2013). Part of the reason they reported not being up to date was a low level of research utilization.

Concerns about ULPSSI rehabilitation were also described by 15 stroke survivors who were interviewed about their experience of ULPSSI and rehabilitation (Doyle, Bennett, & Dudgeon, 2013b). Survivors reported that ULPSSI significantly affected their participation in meaningful activities yet often recounted not receiving any, or adequate, ULPSSI rehabilitation. They also identified not being asked about their preferences for rehabilitation or being included in decision making. Shared decision making involves not just valuing clients’ views about treatment options but also determining their preferences for their role in decision making (Légaré, Ratté, Gravel, & Graham, 2008). Taken together, these studies indicate a need to address barriers to providing evidence-based ULPSSI interventions and encourage use of shared decision making to ultimately improve outcomes.

Knowledge Translation

The knowledge translation process has been proposed as a means for reducing the gap between research and practice (Colquhoun, Letts, Law, MacDermid, & Missiuna, 2010). Knowledge translation is defined as “ensuring that stakeholders are aware of and use research evidence to inform their health and healthcare decision-making” (Grimshaw, Eccles, Lavis, Hill, & Squires, 2012, p. 2). Although some observers have argued that the knowledge that is translated should ideally be from synthesized research (Grimshaw et al., 2012), others have recognized that both research-based and experiential knowledge are important (Graham et al., 2006). One conceptual framework increasingly used to guide knowledge translation is the Knowledge to Action framework, which consists of two phases: The first phase focuses on generating knowledge, and the second focuses on applying knowledge (the action cycle;Graham et al., 2006). This action cycle involves identifying knowledge and practice gaps; understanding the barriers for using that specific knowledge; selecting, tailoring, and implementing interventions to promote and monitor the knowledge utilization; and evaluating the impact and finding ways to sustain its use (Graham et al., 2006; Metzler & Metz, 2010). A variety of approaches are used to improve knowledge uptake, including practice audit, opinion leaders, communities of practice, creating cultures of change, mentoring, continuing professional education, and using action plans and educational materials (Grimshaw et al., 2012).

Continuing Professional Education

Continuing professional education (CPE) is a primary approach occupational therapists use to maintain and improve their knowledge and skills and stay current with research evidence (Bennett et al., 2003; Grimshaw et al., 2012). CPE aims to improve health professionals’ knowledge, skills, and confidence, assuming that doing so improves health care practices and ultimately patients’ health outcomes. Although behavior change from CPE has been found to be small, larger effects may be achieved when CPE is interactive, uses multiple methods, and is designed for a small, single, disciplined group (Grimshaw et al., 2012; Mansouri & Lockyer, 2007).

Using theory to design and evaluate educational interventions to facilitate knowledge translation enables exploration and interpretation of the results, thus allowing refinement of the intervention and informing future translational activities (Colquhoun et al., 2010; Davies, Walker, & Grimshaw, 2010). Two theories commonly informing the design of educational interventions include Adult Learning Theory (ALT; Knowles, Holton, Swanson, & Holton, 1998) and the Theory of Planned Behavior (TPB; Fishbein & Ajzen, 1975).

ALT recognizes that adult learners are internally motivated, self-directed, practical, and goal and relevancy oriented; bring life experiences and knowledge to learning situations; and value being respected (Knowles et al., 1998). An Institute of Medicine (2010) report called for the incorporation of ALT principles into the design of continuing education for health professionals to improve learning outcomes. Whereas ALT focuses on how adults learn best, when using CPE as an intervention for the purposes of knowledge translation, this focus needs to extend to approaches that also target behavioral change.

TPB, a cognitive–behavioral model focused on individual behavior change, has been applied to knowledge translation interventions on the basis of the premise that knowledge translation ultimately aims to change behavior (Colquhoun et al., 2010). The predominant principle of TPB is that a person’s intention to perform a behavior is a key determinant of that behavior and is the best predictor of a deliberate behavior (Fishbein & Ajzen, 1975). This theory posits that intentions are a function of three factors: attitudes, subjective norms, and perceived behavioral control. Attitudes reflect the person’s beliefs about the outcomes associated with the particular behavior and whether the behavior is viewed favorably or unfavorably. Subjective norms are the perceived social pressures or judgments of others to perform or not perform the behavior. The perceived skills and opportunities available to perform the behavior are defined as the person’s perceived behavioral control.

Evaluation of attitudes, subjective norms, and perceived behavioral control related to the target behavior can help in the design of CPE to address these issues and may thereby have an impact on intentions and behavior (Casper, 2007). For example, in a randomized controlled trial of continuing medical education classes consisting of 94 mental health practitioners, Casper (2007) found that a TPB-based continuing medical education program was significantly more effective than a standard program for increasing the practitioner’s utilization of an evaluation tool assessing clients’ felt employment needs.

Limited studies in the rehabilitation field have specifically used theory to develop and deliver CPE aimed at facilitating knowledge translation. Petzold et al. (2012) used the Knowledge to Action framework and incorporated principles of Learner Centered Theory and Bloom’s taxonomy to guide design of a 1-day CPE and reinforcement session about poststroke unilateral spatial neglect management with 20 occupational therapists. They found improved knowledge about best practice for poststroke unilateral spatial neglect and self-efficacy in evidence-based practice activities. Petzold et al. suggested that such theoretically driven CPE may help close research–practice gaps in other rehabilitation areas.

In summary, a need exists to support therapists in the management of ULPSSI and use of shared decision making. Development and evaluation of theoretically informed CPE may address this need, contribute to knowledge translation efforts in this area and, ultimately, improve health outcomes for stroke survivors. In this study, we therefore aimed to (1) evaluate the feasibility of a 1-day CPE, based on TPB and ALT specific to ULPPSI, and (2) evaluate the effect of a theory-based CPE on therapists’ knowledge, attitudes, perceived behavioral control, and behavioral intentions about ULPSSI management, shared decision making, and research utilization.

Method

Research Design

This study was a single-group pretest–posttest quasi-experimental feasibility study. Approval for study procedures was given by one of the Ethics Review Boards at the University of Queensland, St. Lucia, Queensland, Australia, and consent was obtained from all study participants.

Participants

Occupational therapists working with stroke survivors in the Pacific Northwest of the United States were recruited by posters placed in workplaces and therapy networks in that area advertising a free workshop on ULPSSI. Participants from the first workshop also recruited peers for the second session.

Procedure

TPB recommends initially conducting an elicitation study to identify commonly held behavioral, normative, and control beliefs about the target behavior in a representative population to inform development of the questionnaire, intervention, or both (Ajzen, 2006; Ajzen & Fishbein, 1980). Accordingly, we emailed participants an elicitation questionnaire to complete online before the workshop. Therapists then attended one of two 8-hr workshops (described in the next section). Therapists completed a questionnaire at the beginning of the workshop in addition to a postworkshop evaluation form.

Intervention

Workshop Design.

An 8-hr workshop using ALT and TPB was designed to improve occupational therapists’ knowledge, attitudes, perceived control, and behaviors regarding ULPSSI management, research utilization, and shared decision making. We used the results of the pre-workshop elicitation questionnaire, which was based on guidelines suggested by Francis et al. (2004), to inform the workshops’ design and content emphasis. The behaviors of interest concerned sensory assessment behavior (e.g., using standardized testing), using ULPSSI interventions, involving clients in decision making, and keeping up to date with research about ULPSSI management. On the elicitation questionnaire, participants were asked to respond to open-ended questions regarding their beliefs about these behaviors, including (1) the perceived advantages and disadvantages, (2) people who are important to them who might approve or disapprove or other social influences, and (3) factors or circumstances that would facilitate or provide barriers to these behaviors.

The workshop modules were designed to incorporate the results of the elicitation questionnaire. For example, participants identified lack of assessment skills, lack of availability of assessments, and difficulty relating the test scores to function as barriers to standardized assessment use. These findings resulted in a module that incorporated how to obtain assessments, assessment details, how to relate assessment results to function, and practice in assessment use for skill development. This module aimed to improve perceived control (practitioners’ confidence in using assessments) and reduce barriers (how to find and use the assessments). This process was repeated for each component of the elicitation questionnaire results.

Written action plan sheets, consistent with TPB, were used at the completion of each module, challenging therapists to identify new knowledge, behaviors they could incorporate in their setting, and resources needed to do this and to develop 4-wk behavioral goals for incorporating this new knowledge into their workplace (Casper, 2008; Rodriguez, Marquett, Hinton, McBride, & Gallagher-Thompson, 2010). The ALT principles used in this workshop included drawing on participants’ knowledge and experience, acknowledging their experience, and incorporating experiential learning based on real cases during the workshop.

The workshops were conducted by one educator (Susan D. Doyle), who has >30 yr experience as an occupational therapist and was completing her doctorate in the area of stroke rehabilitation. A written manual, digital slides, and a script were used to enhance consistency in content and presentation between workshops. To reduce any influence on the second workshop presentation, no alterations were made, nor were preliminary results reviewed before the second workshop.

Workshop Content.

The workshop modules included understanding ULPSSI, ULPSSI evaluation (e.g., use of standardized assessments), potential for recovery poststroke, evidence on the effects of interventions, survivors’ perspective, understanding decision making under conditions of uncertainty, and resources for updating knowledge. Information from our previous research was provided to participants to increase their awareness of research–practice gaps. This information included results from a survey of occupational therapists’ current practice patterns with ULPSSI and their related educational needs (Doyle, Bennett, & Gustafsson, 2013), qualitative interviews about factors influencing therapists’ decision making related to ULPSSI (Doyle, Bennett, & Dudgeon, 2013a), and a qualitative study of stroke survivors’ perspectives on ULPSSI and rehabilitation preferences (Doyle, Bennett, & Dudgeon, 2013b). Information from a systematic review of the effect of interventions for ULPSSI (Doyle et al., 2010) was also updated with findings from randomized controlled trials published since its completion.

Outcome Measures

We used specifically designed pre- and postworkshop questionnaires, guided in part by TPB. The questionnaire contained five sections. The first section (included only in the preworkshop questionnaire) collected demographic and practice setting information, including age, gender, educational level, practice setting, experience, current caseload of stroke patients, and previous attendance at a course on ULPSSI.

The next section consisted of nine 5-point Likert-scale questions about current practice behaviors related to ULPSSI with anchors ranging from 1 = strongly disagree to 5 = strongly agree. These questions asked about utilization of ULPSSI standardized assessments, use of ULPSSI remedial and compensatory interventions, information provision to clients, determination of clients’ preferences for involvement in decision making, and approaches to looking for evidence and resources to support practice. These items were rephrased in the postworkshop questionnaire to ask about therapists’ intended future behaviors in these same areas.

The third section contained fourteen 5-point Likert-scale questions using constructs from TPB and with anchors ranging from 1 = strongly disagree to 5 = strongly agree. Specifically, 8 items asked about perceived behavioral control (confidence performing the behavior) regarding choosing and providing ULPSSI assessments and interventions, providing information to clients, sharing decision making, and being up to date with research regarding ULPSSI. Four items asked about subjective normative beliefs regarding ULPSSI interventions, and 2 items asked about attitudes toward providing interventions. Each item was scored using the Likert-scale choice as the individual raw score, with a possible range from 1 to 5.

The fourth section included 10 multiple-choice questions that sought to determine therapists’ knowledge about ULPSSI, including the incidence, types of sensory impairments, and research regarding ULPSSI interventions. We calculated the total number of questions correct for this section.

To measure attitudes toward client-centered practice, we used the Patient–Practitioner Orientation Scale (PPOS; Krupat, Hiam, Fleming, & Freeman, 1999). The PPOS is an 18-item scale that measures attitudes on two dimensions, Caring and Sharing, with item scores ranging from 1 to 6. It is designed to differentiate patient- versus practitioner-oriented perspectives in the patient–practitioner relationship (Ross & Haidet, 2011). The practitioner’s willingness to share information, control, and power within the relationship is measured by the nine Sharing dimension items (Ross & Haidet, 2011). The scale’s validity among medical students and practitioners was established by Krupat et al. (1999) and Shaw, Woiszwillo, and Krupat (2012), and its reliability and internal consistency were established by Krupat et al. The 9 items on the Caring dimension measure the value placed on warmth, support, and psychosocial issues by the practitioner (Ross & Haidet, 2011). We calculated pre- and postworkshop total scores for the PPOS as well as Caring and Sharing subscale total scores. Total PPOS scores could range from 18 to 108; subscale scores ranged from 9 to 54.

We included questions seeking the participants’ evaluation of the workshop content, presentation, and perception of meeting the course objectives in the postworkshop questionnaire. Participants were also asked about their perceptions of the presenter’s knowledge of the material, adequacy of material presentation, and suitability of the facility using nine 5-point Likert-scale questions with anchors ranging from 1 = poor to 5 = excellent. Participants were asked for general comments regarding the workshop and whether they would recommend it to others.

Data Analysis

We analyzed the elicitation questionnaires using content analysis to identify commonly occurring themes and issues. Data from the pre- and postworkshop questionnaires were analyzed using PASW Statistics 18 (SPSS Inc., Chicago). Descriptive statistics were calculated for the demographic data. Current behavior and intended behavior were highly related but different concepts and were therefore not directly compared. Rather, we calculated frequencies for the combined strongly agree and agree categories for each statement separately for preworkshop current behavior items and postworkshop intended behavior questionnaire items. Total correct pre- and postworkshop knowledge scores were compared using paired t tests. Data for attitudes, subjective norms, perceived behavioral control, and PPOS total scores were inspected for normality, and because limited evidence of skew existed, we compared pre- and posttest scores using paired t tests. Significance was set at p ≤ .01 to take into account multiple comparisons.

Descriptive statistics summarized the data evaluating the workshop content and process. Data were collapsed, with “very good” and “excellent” combined into one category, “good” into another category, and “poor” and “fair” combined into a third category.

Results

Participants and Recruitment

Nine participants attended the first workshop, and 10 attended the second workshop. Of the 19 participants, 8 had bachelor’s degree entry-level qualifications and 11 had master’s degrees. One participant reported attending a prior CPE that addressed ULPSSI, and 2 did not answer the question. Three therapists reported working in acute hospital settings, 4 in outpatient clinics, 2 in inpatient rehabilitation, 1 in home health, 3 in skilled nursing facilities, and 6 in mixed-practice settings. Therapists ranged in age from 26 to 65 yr (mean [M] = 38.7, standard deviation [SD] = 10.8) and had a large range of experience as occupational therapists (range = 1–42 yr, mean = 11.4, SD = 11.2) and with stroke survivors (range = 1–42 yr, M = 9.8, SD = 11.6). The mean percentage of therapists’ caseload consisting of stroke survivors was 19% (range = 1%–45%, SD = 12.0), and the majority saw survivors who were <3 mo poststroke (0–6 wk = 31.6%; >6 wk–3 mo = 42.1%; >6 mo–1 yr = 5.3%; >1 yr = 21.1%; percentages total >100% due to rounding).

Elicitation Questionnaire

Nine respondents anonymously completed the online elicitation questionnaire before the workshops. The key barriers and disadvantages participants identified that needed addressing included lack of skills and knowledge about the management of ULPSSI and shared decision making; lack of time to locate evidence and use new assessments, interventions, and shared decision making; and lack of resources. Methods that were suggested to address these barriers—such as using “cheat sheets” to remind them of the key principles of sensory retraining, knowing where or how to find full text of articles, or being provided with success stories or examples of shared decision making—were either discussed in the workshop or incorporated into the educational modules, handouts, and action sheet questions. The advantages that were identified in the elicitation questionnaire were specifically acknowledged and discussed during the workshop. The perceived barriers, social influences, and disadvantages that were identified were discussed in the workshop to address associated beliefs and attitudes and to facilitate participation in finding solutions.

Outcome Measures

Current and Intended Behaviors.

Visual inspection of Table 1 for current and intended behaviors shows a large difference between pre- and postworkshop frequencies for all behaviors. For example, although only 4 participants (21.1%) reported that they currently asked clients for their preferences regarding involvement in decisions about interventions for their ULPSSI, after the workshop 18 (94.7%) agreed they intended to do so in future. The percentage of agreement for current behaviors ranged from 5.3% (having read or looked for research articles in the past month) to 52.6% (using standardized assessments on initial assessment for ULPSSI). After the workshop, the percentages of agreement for intended behaviors ranged from 84.2% (intending to read or look for research articles in the next month) to 100% (intending to provide clients information about evidence for ULPSSI interventions).

Table 1.

Current or Intended Behaviors Related to ULPSSI

Behavioral Statement	n	Current Behavior (Preworkshop), Strongly Agree or Agree, n (%)	Intended Behavior (Postworkshop), Strongly Agree or Agree, n (%)
I use/intend to use standardized function-based sensory assessments when I complete my initial evaluation with stroke patients.	19	10 (52.6)	18 (94.7)
I use/intend to use standardized function-based sensory assessments when completing my discharge evaluation of a stroke patient.	18	4 (22.2)	17 (94.4)
I use/intend to use graded sensory reeducation–based interventions targeted to remediate specific ULPSSI.	19	7 (36.8)	18 (94.7)
I use/intend to use interventions specifically targeted to compensate for sensory impairments in the upper limb for stroke patients.	19	9 (47.4)	18 (94.7)
I provide/intend to provide information to my clients about evidence for interventions for their sensory impairment.	19	9 (47.4)	19 (100)
I ask/intend to ask my clients what their preferences are about being involved in decisions about interventions that might be used for their sensory impairments.	19	4 (21.1)	18 (94.7)
Prior to finishing rehabilitation with my client, I usually/intend to confirm they know what to do in the future to either continue working on sensory impairment issues or know how to get further help for this.	19	5 (26.3)	16 (84.2)
I have/intend to read or looked for research articles related to sensory impairments after stroke in the past 6 mo.	19	1(5.3)	16 (84.2)
I have reviewed/intend to review electronic databases regularly in the past 6 mo to help inform my practice about sensory impairments.	19	2 (10.5)	17 (89.5)

Note. ULPSSI = upper-limb poststroke sensory impairments.

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Table 1.

Current or Intended Behaviors Related to ULPSSI

Behavioral Statement	n	Current Behavior (Preworkshop), Strongly Agree or Agree, n (%)	Intended Behavior (Postworkshop), Strongly Agree or Agree, n (%)
I use/intend to use standardized function-based sensory assessments when I complete my initial evaluation with stroke patients.	19	10 (52.6)	18 (94.7)
I use/intend to use standardized function-based sensory assessments when completing my discharge evaluation of a stroke patient.	18	4 (22.2)	17 (94.4)
I use/intend to use graded sensory reeducation–based interventions targeted to remediate specific ULPSSI.	19	7 (36.8)	18 (94.7)
I use/intend to use interventions specifically targeted to compensate for sensory impairments in the upper limb for stroke patients.	19	9 (47.4)	18 (94.7)
I provide/intend to provide information to my clients about evidence for interventions for their sensory impairment.	19	9 (47.4)	19 (100)
I ask/intend to ask my clients what their preferences are about being involved in decisions about interventions that might be used for their sensory impairments.	19	4 (21.1)	18 (94.7)
Prior to finishing rehabilitation with my client, I usually/intend to confirm they know what to do in the future to either continue working on sensory impairment issues or know how to get further help for this.	19	5 (26.3)	16 (84.2)
I have/intend to read or looked for research articles related to sensory impairments after stroke in the past 6 mo.	19	1(5.3)	16 (84.2)
I have reviewed/intend to review electronic databases regularly in the past 6 mo to help inform my practice about sensory impairments.	19	2 (10.5)	17 (89.5)

Note. ULPSSI = upper-limb poststroke sensory impairments.

Attitudes, Subjective Norms, and Perceived Behavioral Control.

Pre- and posttest scores for attitudes, perceived behavioral control, subjective norms, and beliefs are presented in Table 2 together with change scores and t-test results. We found statistically significant improvements between preworkshop and postworkshop for participants’ attitude about interventions being beneficial for clients (p = .00), participants’ confidence in their capability of performing all behaviors addressed by this workshop (perceptions of behavioral control), and feeling more up to date in the area of ULPSSI. The only significant change noted in subjective norms was that after the workshop, participants felt under more pressure to provide interventions for people with sensory impairments than before the workshop. Participants’ beliefs that sensation affects functional upper-limb use and that ULPSSI interventions are effective were significantly greater postworkshop.

Table 2.

Perceived Behavioral Control, Attitudes, and Perceived Subjective Norms and Beliefs Regarding the Management of ULPSSI (N = 19)

Element	Mean (Standard Deviation)		Mean Changea	t	df	p
Element	Pretest	Posttest	Mean Changea	t	df	p
Perceived Behavioral Control
I feel confident treating patients with sensory impairments after stroke.	2.42 (0.84)	3.79 (0.42)	1.37	−8.72	18	.00*
I am confident deciding on the best assessment for sensory impairments.	2.16 (0.69)	3.68 (0.48)	1.52	−8.61	18	.00*
I am comfortable explaining how the results of the sensory assessments relate to the functional use of the arm.	2.63 (0.96)	3.84 (0.69)	1.21	−5.75	18	.00*
I am comfortable choosing interventions to remediate sensory impairments based on my assessment results.	2.11 (0.66)	4.05 (0.41)	1.94	−13.66	18	.00*
I am confident explaining these sensory interventions to my patients.	2.16 (0.77)	3.74 (0.56)	1.58	−8.96	18	.00*
I feel confident assessing how effective my interventions for sensory impairment are.	2.16 (0.69)	3.63 (0.60)	1.47	−7.10	18	.00*
I am comfortable choosing interventions that are the most effective for sensory impairments.	4.16 (0.60)	4.79 (0.42)	0.63	−4.03	18	.00*
I feel up to date with current research evidence about the effectiveness of sensory interventions for people with sensory impairments following stroke.	1.92 (0.76)	4.08 (0.86)	2.16	6.40	12	.00*
Attitudes
Overall I think that providing interventions for sensory impairments is beneficial.	4.32 (0.58)	4.84 (0.38)	0.52	−3.75	18	.00*
Overall I think that providing interventions for sensory impairments is good practice.	3.79 (0.79)	4.11 (0.94)	0.32	−1.06	18	.30
Perceived Subjective Norms
It is expected of me that I provide interventions for people with sensory impairments.	3.37 (1.07)	3.53 (0.96)	0.16	−0.51	18	.62
Other therapists think I should provide interventions for people with sensory impairments.	2.74 (1.05)	2.95 (1.03)	0.21	−0.66	18	.52
I feel under pressure to provide interventions for people with sensory impairments.	2.47 (1.12)	4.05 (0.62)	1.58	−6.14	18	.00*
Beliefs
Sensory interventions for clients after stroke are effective.	3.06 (0.93)	3.88 (0.72)	0.82	2.78	15	.01
Upper-limb functional use after stroke has been impacted by sensory impairments.	3.84 (0.90)	4.42 (0.51)	0.58	−2.80	18	.01

Note. ULPSSI = upper-limb poststroke sensory impairments.

aMean change scores represent the difference between the mean score of the sample on the postworkshop measure and the preworkshop measure.

*Significant at p ≤ .00.

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Table 2.

Perceived Behavioral Control, Attitudes, and Perceived Subjective Norms and Beliefs Regarding the Management of ULPSSI (N = 19)

Element	Mean (Standard Deviation)		Mean Changea	t	df	p
Element	Pretest	Posttest	Mean Changea	t	df	p
Perceived Behavioral Control
I feel confident treating patients with sensory impairments after stroke.	2.42 (0.84)	3.79 (0.42)	1.37	−8.72	18	.00*
I am confident deciding on the best assessment for sensory impairments.	2.16 (0.69)	3.68 (0.48)	1.52	−8.61	18	.00*
I am comfortable explaining how the results of the sensory assessments relate to the functional use of the arm.	2.63 (0.96)	3.84 (0.69)	1.21	−5.75	18	.00*
I am comfortable choosing interventions to remediate sensory impairments based on my assessment results.	2.11 (0.66)	4.05 (0.41)	1.94	−13.66	18	.00*
I am confident explaining these sensory interventions to my patients.	2.16 (0.77)	3.74 (0.56)	1.58	−8.96	18	.00*
I feel confident assessing how effective my interventions for sensory impairment are.	2.16 (0.69)	3.63 (0.60)	1.47	−7.10	18	.00*
I am comfortable choosing interventions that are the most effective for sensory impairments.	4.16 (0.60)	4.79 (0.42)	0.63	−4.03	18	.00*
I feel up to date with current research evidence about the effectiveness of sensory interventions for people with sensory impairments following stroke.	1.92 (0.76)	4.08 (0.86)	2.16	6.40	12	.00*
Attitudes
Overall I think that providing interventions for sensory impairments is beneficial.	4.32 (0.58)	4.84 (0.38)	0.52	−3.75	18	.00*
Overall I think that providing interventions for sensory impairments is good practice.	3.79 (0.79)	4.11 (0.94)	0.32	−1.06	18	.30
Perceived Subjective Norms
It is expected of me that I provide interventions for people with sensory impairments.	3.37 (1.07)	3.53 (0.96)	0.16	−0.51	18	.62
Other therapists think I should provide interventions for people with sensory impairments.	2.74 (1.05)	2.95 (1.03)	0.21	−0.66	18	.52
I feel under pressure to provide interventions for people with sensory impairments.	2.47 (1.12)	4.05 (0.62)	1.58	−6.14	18	.00*
Beliefs
Sensory interventions for clients after stroke are effective.	3.06 (0.93)	3.88 (0.72)	0.82	2.78	15	.01
Upper-limb functional use after stroke has been impacted by sensory impairments.	3.84 (0.90)	4.42 (0.51)	0.58	−2.80	18	.01

Note. ULPSSI = upper-limb poststroke sensory impairments.

aMean change scores represent the difference between the mean score of the sample on the postworkshop measure and the preworkshop measure.

*Significant at p ≤ .00.

Knowledge.

The mean score for ULPSSI knowledge preworkshop was 3.32 (SD = 1.06) and increased to a mean knowledge score of 8.53 (SD = 0.91) postworkshop and was statistically significant, t(18) = −15.0, p = .00.

Client-Centered Care.

We noted significantly lower PPOS scores, indicating more patient centeredness, postworkshop (M = 49.22, SD = 6.80) compared with preworkshop (M = 54.56, SD = 6.39), t(17) = 4.63, p = .00. Significant improvements in other aspects of patient centeredness were also noted in both the Caring subscale scores (preworkshop mean = 27.67, SD = 4.10; postworkshop M = 25.72, SD = 4.31, t[17] = 2.87, p = .01) and Sharing subscale scores (preworkshop M = 27.16, SD = 4.29; postworkshop M = 23.63, SD = 3.95, t[18] = 4.35, p = .00).

Feasibility of the Workshop

Use of the TPB and the associated elicitation study was helpful in guiding the development of the workshop but also proved invaluable for proactively addressing beliefs, attitudes, and concerns during the workshop. Recruitment proved more difficult than anticipated even though the workshop was free. Many participants reported that their peers would prefer the workshop be held on a weekday versus a Sunday to allow use of a paid education day, easier access to child care, and decreased interruption in family time or activities. Participants also requested further time to practice the evaluations and interventions that were reviewed in the workshop.

Evaluation of Workshop Content and Process

Eighteen participants returned workshop evaluations. Participants were asked to comment on a number of different aspects of the content, process, facilitation, and practical arrangements of the workshop. All 18 reported that all aspects of the workshop were excellent to good. All the participants completing this question (17) would recommend this course to others. Ten participants provided comments to an open-ended question about the workshop, with many indicating the workshop would support their clinical practice. These comments are illustrated by 1 participant, who said, “This was wonderful. I will be able to USE the information learned today and put it into practice,” and by another who stated, “Information provided was easily digestible with resources to back it up. Provided ideas that can be used immediately and information regarding what is current. Most importantly, you gave us tools to keep learning and stay current.” Finally, the workshop’s importance was highlighted by another participant, who said, “This is a topic that seems overlooked but deserves attention to improve therapists’ knowledge, comfort, and ability to access resources when evaluating/treating stroke patients.”

Discussion

This study is the first to test a theoretically based workshop aimed at improving knowledge, attitudes, perceived behavioral control, and behavioral intentions about the management of ULPSSI, shared decision making, and awareness and use of research to inform practice. The results indicated the potential for a workshop such as this one, based on principles from the TPB and ALT, to make a difference in key variables conceptualized as influencing practice behavior. Specifically, we found improvements in knowledge, attitudes, and perceived behavioral control and changes from reports of current to intended behaviors for ULPSSI management. Additionally, a much higher percentage of participants agreed they intended to carry out behaviors related to remaining current with research evidence when compared with their self-reported use of these behaviors in the month before the workshop. Such active engagement in professional development activities is recommended to develop skills required for research utilization (Craik & Rappolt, 2006).

Similar results were found in a feasibility study of 20 occupational therapists attending a day-long workshop and 8-wk reinforcement with Web-based materials and discussion forum to improve their management of acute poststroke unilateral spatial neglect (Petzold et al., 2012). The workshop was designed on the basis of perceived barriers to the use of best practice for management of poststroke unilateral spatial neglect identified in interviews of occupational therapists, and it used learning theories to guide its development. Results indicated that this workshop and follow-up reinforcement improved knowledge of best practice for unilateral spatial neglect management and perceived self-efficacy in carrying out evidence-based practice activities.

Similar to the study by Petzold et al. (2012), the intervention in our study was selected as a means to address barriers to using standardized assessments and providing interventions with evidence of effectiveness. The Knowledge to Action action cycle suggests that once a research–practice gap is evident, identified barriers should be addressed with carefully selected, tailored interventions (Graham et al., 2006). This workshop addressing ULPSSI management was informed by research that identified gaps between evidence about ULPSSI and common practice patterns among occupational therapists working in this area, as well as barriers including therapists’ lack of confidence and knowledge regarding ULPSSI (Doyle, Bennett, & Gustafsson, 2013). The workshop attempted to address factors internal to the individual (knowledge, attitudes, perceived behavioral control, and skills) and discussed external factors that might influence practice through the use of a range of theoretically guided strategies.

Regarding shared decision making, the preliminary results of this study indicate improvements in therapists’ attitudes toward, perceived behavioral control for, and changes from reports of current behavior to intended behaviors regarding informing clients about evidence for ULPSSI interventions and seeking their preferences for decision-making involvement. Shared decision making is important because it improves client satisfaction and adherence to interventions and may improve health outcomes (Elwyn, Edwards, & Kinnersley, 1999).

In addition to providing preliminary results about the possible effects of this intervention, this study provided information about its acceptability and feasibility. All participants were very positive about both the workshop’s content and its process and recommended further sessions to reinforce their confidence and develop their skills. In practical terms, issues that would need to be carefully considered if this intervention was to be tested using a randomized controlled trial design in the future include methods to recruit a sufficient sample size, training other workshop facilitators to provide the intervention, and manualizing the intervention to enhance fidelity and consistency of delivery between workshop facilitators. Future research should also consider specifically addressing external barriers to ULPSSI management such as lack of time and resources and determining methods for measuring actual behavior change and relevant health outcomes for clients.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

Theory-driven CPE can improve attitudes, knowledge, and perceived control for the management of ULPSSI and potentially influence practice.
Attitudes, knowledge, and perceived control for the use of behaviors important for shared decision making can be improved through theory-based CPE.
Using the Knowledge to Action framework can support occupational therapists to more systematically develop approaches to close the gaps between research and practice.

Limitations

This study had a small sample size and used a simple pretest–posttest design with no control group. Moreover, although data were inspected for normality before using t tests, the small sample size restricts confidence in the analysis and interpretation of results. Thus, the results should be considered as only preliminary.

However, because this was a feasibility study designed to test recruitment, acceptability of the intervention, and appropriateness of outcome measures, the design was a reasonable choice. The results provide only preliminary information about the potential of a theoretically informed workshop to bring about changes in knowledge, attitudes, perceived behavioral control, and intended behaviors, and a larger randomized controlled trial design is necessary to confirm these findings. Not all the participants (56%, 9 of 16) completed the elicitation questionnaire, so this missing data may also have affected the ability to accurately identify the factors that had an impact on therapists’ intended behavior and address these issues in the CPE based on TPB. Moreover, the generalizability of the preliminary results is limited by the recruitment of participants from a convenience sample in one geographic location.

It was not possible to directly compare preworkshop and postworkshop intended behaviors because the preworkshop questionnaire asked about perceived current behaviors, which is a related yet different concept. Questionnaires designed to capture variables relevant to the TPB recommend that intended behaviors be measured before and after the intervention (Francis et al., 2004), which is recommended in future research. Further research establishing the reliability and validity of the outcome measures is recommended.

Conclusion

On the basis of this feasibility study, it appears that a theory-based CPE has the potential to affect clinicians’ knowledge, attitudes, perceived behavioral control, and behavioral intentions about ULPSSI management, shared decision making, and awareness and use of research to inform practice. Further development of a randomized controlled trial to evaluate this intervention is warranted, incorporating the recommendations from this feasibility study to improve recruitment, study design, and usefulness of the outcome measures. This study is important in improving understanding of knowledge translation by occupational therapists.

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Table 1.

Current or Intended Behaviors Related to ULPSSI

Behavioral Statement	n	Current Behavior (Preworkshop), Strongly Agree or Agree, n (%)	Intended Behavior (Postworkshop), Strongly Agree or Agree, n (%)
I use/intend to use standardized function-based sensory assessments when I complete my initial evaluation with stroke patients.	19	10 (52.6)	18 (94.7)
I use/intend to use standardized function-based sensory assessments when completing my discharge evaluation of a stroke patient.	18	4 (22.2)	17 (94.4)
I use/intend to use graded sensory reeducation–based interventions targeted to remediate specific ULPSSI.	19	7 (36.8)	18 (94.7)
I use/intend to use interventions specifically targeted to compensate for sensory impairments in the upper limb for stroke patients.	19	9 (47.4)	18 (94.7)
I provide/intend to provide information to my clients about evidence for interventions for their sensory impairment.	19	9 (47.4)	19 (100)
I ask/intend to ask my clients what their preferences are about being involved in decisions about interventions that might be used for their sensory impairments.	19	4 (21.1)	18 (94.7)
Prior to finishing rehabilitation with my client, I usually/intend to confirm they know what to do in the future to either continue working on sensory impairment issues or know how to get further help for this.	19	5 (26.3)	16 (84.2)
I have/intend to read or looked for research articles related to sensory impairments after stroke in the past 6 mo.	19	1(5.3)	16 (84.2)
I have reviewed/intend to review electronic databases regularly in the past 6 mo to help inform my practice about sensory impairments.	19	2 (10.5)	17 (89.5)

Note. ULPSSI = upper-limb poststroke sensory impairments.

View Large

Table 1.

Current or Intended Behaviors Related to ULPSSI

Behavioral Statement	n	Current Behavior (Preworkshop), Strongly Agree or Agree, n (%)	Intended Behavior (Postworkshop), Strongly Agree or Agree, n (%)
I use/intend to use standardized function-based sensory assessments when I complete my initial evaluation with stroke patients.	19	10 (52.6)	18 (94.7)
I use/intend to use standardized function-based sensory assessments when completing my discharge evaluation of a stroke patient.	18	4 (22.2)	17 (94.4)
I use/intend to use graded sensory reeducation–based interventions targeted to remediate specific ULPSSI.	19	7 (36.8)	18 (94.7)
I use/intend to use interventions specifically targeted to compensate for sensory impairments in the upper limb for stroke patients.	19	9 (47.4)	18 (94.7)
I provide/intend to provide information to my clients about evidence for interventions for their sensory impairment.	19	9 (47.4)	19 (100)
I ask/intend to ask my clients what their preferences are about being involved in decisions about interventions that might be used for their sensory impairments.	19	4 (21.1)	18 (94.7)
Prior to finishing rehabilitation with my client, I usually/intend to confirm they know what to do in the future to either continue working on sensory impairment issues or know how to get further help for this.	19	5 (26.3)	16 (84.2)
I have/intend to read or looked for research articles related to sensory impairments after stroke in the past 6 mo.	19	1(5.3)	16 (84.2)
I have reviewed/intend to review electronic databases regularly in the past 6 mo to help inform my practice about sensory impairments.	19	2 (10.5)	17 (89.5)

Note. ULPSSI = upper-limb poststroke sensory impairments.

Table 2.

Perceived Behavioral Control, Attitudes, and Perceived Subjective Norms and Beliefs Regarding the Management of ULPSSI (N = 19)

Element	Mean (Standard Deviation)		Mean Changea	t	df	p
Element	Pretest	Posttest	Mean Changea	t	df	p
Perceived Behavioral Control
I feel confident treating patients with sensory impairments after stroke.	2.42 (0.84)	3.79 (0.42)	1.37	−8.72	18	.00*
I am confident deciding on the best assessment for sensory impairments.	2.16 (0.69)	3.68 (0.48)	1.52	−8.61	18	.00*
I am comfortable explaining how the results of the sensory assessments relate to the functional use of the arm.	2.63 (0.96)	3.84 (0.69)	1.21	−5.75	18	.00*
I am comfortable choosing interventions to remediate sensory impairments based on my assessment results.	2.11 (0.66)	4.05 (0.41)	1.94	−13.66	18	.00*
I am confident explaining these sensory interventions to my patients.	2.16 (0.77)	3.74 (0.56)	1.58	−8.96	18	.00*
I feel confident assessing how effective my interventions for sensory impairment are.	2.16 (0.69)	3.63 (0.60)	1.47	−7.10	18	.00*
I am comfortable choosing interventions that are the most effective for sensory impairments.	4.16 (0.60)	4.79 (0.42)	0.63	−4.03	18	.00*
I feel up to date with current research evidence about the effectiveness of sensory interventions for people with sensory impairments following stroke.	1.92 (0.76)	4.08 (0.86)	2.16	6.40	12	.00*
Attitudes
Overall I think that providing interventions for sensory impairments is beneficial.	4.32 (0.58)	4.84 (0.38)	0.52	−3.75	18	.00*
Overall I think that providing interventions for sensory impairments is good practice.	3.79 (0.79)	4.11 (0.94)	0.32	−1.06	18	.30
Perceived Subjective Norms
It is expected of me that I provide interventions for people with sensory impairments.	3.37 (1.07)	3.53 (0.96)	0.16	−0.51	18	.62
Other therapists think I should provide interventions for people with sensory impairments.	2.74 (1.05)	2.95 (1.03)	0.21	−0.66	18	.52
I feel under pressure to provide interventions for people with sensory impairments.	2.47 (1.12)	4.05 (0.62)	1.58	−6.14	18	.00*
Beliefs
Sensory interventions for clients after stroke are effective.	3.06 (0.93)	3.88 (0.72)	0.82	2.78	15	.01
Upper-limb functional use after stroke has been impacted by sensory impairments.	3.84 (0.90)	4.42 (0.51)	0.58	−2.80	18	.01

Note. ULPSSI = upper-limb poststroke sensory impairments.

aMean change scores represent the difference between the mean score of the sample on the postworkshop measure and the preworkshop measure.

*Significant at p ≤ .00.

View Large

Table 2.

Perceived Behavioral Control, Attitudes, and Perceived Subjective Norms and Beliefs Regarding the Management of ULPSSI (N = 19)

Element	Mean (Standard Deviation)		Mean Changea	t	df	p
Element	Pretest	Posttest	Mean Changea	t	df	p
Perceived Behavioral Control
I feel confident treating patients with sensory impairments after stroke.	2.42 (0.84)	3.79 (0.42)	1.37	−8.72	18	.00*
I am confident deciding on the best assessment for sensory impairments.	2.16 (0.69)	3.68 (0.48)	1.52	−8.61	18	.00*
I am comfortable explaining how the results of the sensory assessments relate to the functional use of the arm.	2.63 (0.96)	3.84 (0.69)	1.21	−5.75	18	.00*
I am comfortable choosing interventions to remediate sensory impairments based on my assessment results.	2.11 (0.66)	4.05 (0.41)	1.94	−13.66	18	.00*
I am confident explaining these sensory interventions to my patients.	2.16 (0.77)	3.74 (0.56)	1.58	−8.96	18	.00*
I feel confident assessing how effective my interventions for sensory impairment are.	2.16 (0.69)	3.63 (0.60)	1.47	−7.10	18	.00*
I am comfortable choosing interventions that are the most effective for sensory impairments.	4.16 (0.60)	4.79 (0.42)	0.63	−4.03	18	.00*
I feel up to date with current research evidence about the effectiveness of sensory interventions for people with sensory impairments following stroke.	1.92 (0.76)	4.08 (0.86)	2.16	6.40	12	.00*
Attitudes
Overall I think that providing interventions for sensory impairments is beneficial.	4.32 (0.58)	4.84 (0.38)	0.52	−3.75	18	.00*
Overall I think that providing interventions for sensory impairments is good practice.	3.79 (0.79)	4.11 (0.94)	0.32	−1.06	18	.30
Perceived Subjective Norms
It is expected of me that I provide interventions for people with sensory impairments.	3.37 (1.07)	3.53 (0.96)	0.16	−0.51	18	.62
Other therapists think I should provide interventions for people with sensory impairments.	2.74 (1.05)	2.95 (1.03)	0.21	−0.66	18	.52
I feel under pressure to provide interventions for people with sensory impairments.	2.47 (1.12)	4.05 (0.62)	1.58	−6.14	18	.00*
Beliefs
Sensory interventions for clients after stroke are effective.	3.06 (0.93)	3.88 (0.72)	0.82	2.78	15	.01
Upper-limb functional use after stroke has been impacted by sensory impairments.	3.84 (0.90)	4.42 (0.51)	0.58	−2.80	18	.01

Note. ULPSSI = upper-limb poststroke sensory impairments.

aMean change scores represent the difference between the mean score of the sample on the postworkshop measure and the preworkshop measure.

*Significant at p ≤ .00.