Vocational Rehabilitation and Occupational Therapy: Impact of a Knowledge Translation Initiative Eimear Lyons* MSc, BSc, OT & Judith Pettigrew PhD, MA, BSc, OT University of Limerick, Limerick, Ireland *Correspondence Eimear Lyons, Department of Clinical Therapies, Working with Arthritis Program, University of Limerick, Limerick, Ireland. Tel: +353 87 7430670. Email: [email protected]

Published online 12 December 2013 in Wiley Online Library ( DOI: 10.1002/msc.1063

Introduction In musculoskeletal disorders (MSDs) and chronic pain, work disability has been identified as pervasive and costly, from human, societal and economic perspectives (Gignac et al., 2008; Bevan et al., 2009a,2009b; Leon et al., 2009). Vocational rehabilitation (VR) has been defined as: ‘a process to overcome the barriers an individual faces when accessing, remaining or returning to work following injury, illness or impairment’ (Department for Work and Pensions, 2004). VR has the potential to reduce the risk, cost and the negative human effect of work disability (Franche et al., 2005; Briand et al., 2008; Waddell et al., 2008). The integration of VR into a standard healthcare role is reported as necessary but is challenged in many countries which fail to incentivize return to work or resource health-related employment services, or lack policy frameworks to promote work ability (Alsop, 2004; Adam et al., 2010; Szeto et al., 2011). Allied health professionals are encouraged to use an evidence-based model of care to improve the effectiveness of clinical interventions and influence a positive patient outcome in developing areas of practice (Bennett and Bennett, 2000, Law, 2002; McCluskey and Cusick, 2002). Yet, allied health professionals consistently report that they do not have training, time, support or resources to master evidence-based practice (EBP) skills (McCluskey and Cusick, 2002; Rappolt and Tassone, 2002; Bennett et al., 2003; Grol and Grimshaw, 2003; McCluskey, 2003; Haynes et al., 2012; Caldwell et al., 2008; Lin et al., 2010; Murphy and Robinson, 2010). This rings true for VR, with occupational therapists (OTs) feeling 118

under-skilled and lacking knowledge in the field (College of Occupational Therapists, 2008). Barriers to the implementation of EBP in the area of VR include difficulties with knowledge attainment and synthesis (Vachon et al., 2010). The need for improved knowledge translation efforts to support developing areas of practice, such as VR, has been acknowledged (Hakkennes and Dodd, 2008; Lin et al., 2010) and requires clinical focus. Knowledge translation has been defined as a dynamic process involving: ‘synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of patients, provide more effective health services and products, and strengthen the healthcare system’ (Canadian Institutes of Health Research, 2009). Printed education material (PEM), such as guidebooks and clinical guidelines, remains a widely used dissemination strategy to promote knowledge translation in allied health professions (Grimshaw et al., 2004). However, systematic reviews of the impact of PEM and clinical guidelines reveal conflicting data as to their benefit, and as to which dissemination and adjunct educational strategies maximize results.

Methods Objectives The primary objective was to explore the impact of a multi-faceted educational initiative on the VR practices of a group of OTs working in Ireland. Secondary objectives were to investigate if the use of the Musculoskelet. Care 12 (2014) 118–124 © 2013 John Wiley & Sons, Ltd.

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guidebook and adjunct educational methods resulted in a change in VR practice behaviours and processes; to identify factors which influence knowledge translation and the implementation of VR practice by OTs; and to elicit implications for health professionals regarding the development of VR services.

contents and potential clinical application. Expert peer advice was provided by an Alliance member. During the following eight-week phase, the participants were requested to use the guidebook, as clinical opportunity allowed. Email and telephone support, via consultation with a member of the Alliance, was encouraged and was available to all throughout the duration of the study.

Participants Six participants were recruited. These were selfselecting by response to an advertisement through the Association of Occupational Therapists in Ireland (AOTI). Once participants had been identified as meeting the inclusion criteria, an information leaflet and documentation seeking consent was sent to all participants. Table 1 describes the OTs who participated. Ethical approval was attained from the Ethics and Medical Research Committee, St Vincent’s University Hospital, and from the University of Limerick Education and Health Sciences Research Ethics Committee.

Research procedure In 2011, through a participatory action research process, a guidebook on VR for OTs was written by the Irish Alliance of Occupational Therapists working with chronic pain and MSDs. The guidebook contents covered a number of evidence-based topics in relation to the application of VR, including vocational assessment, intervention, legislation and social welfare. All participants received one electronic and one hard copy of the guidebook on commencement of the study. Once they had received these, the participants completed a group teleconference with a member of the Alliance, where the guidebook was introduced and a peer exchange forum was held in regard to the

Data collection At the close of the eight-week phase, one-to-one semi-structured interviews were held with each participant. The interviews explored the impact of the guidebook and educational methods used on the participants’ professional behaviours and processes in relation to VR. The interview schedule was founded on evidence-based findings relative to knowledge translation and practice development in VR for allied health professionals. The schedule was piloted with two peer OTs experienced in the field of practice development. Post-amendments, interviews were undertaken, which averaged 43 minutes in duration (range 31–60 minutes). With permission, these were audio-recorded and later transcribed verbatim by the researcher. Data analysis A transcript of the interview was sent to each participant for member checking within one week. Verification and comments were received and incorporated to enhance validity. Thematic analysis was used to code and analyse the data in all six transcripts. A six-staged guide to effective thematic analysis, as described by Braun and Clarke (2006), was adhered to. Thoughts and reflections were documented in a journal to support the analytical

Table 1. Participant descriptors Participant (Pseudonym)

Years of practice


Area of work

6 24 30 5 13 9

Senior Private practitioner Manager and private practitioner Staff grade Senior Senior

Acute hospital Private practice Manager of HSE regional services; Part-time private practice Acute hospital incorporating rehabilitation services Acute hospital incorporating rehabilitation services Acute hospital incorporating rehabilitation services

Lynn Emma Sarah Claire Anna Jane †

Staff grade: 0–4 years’ practice experience; Senior grade: > 4 years’ practice experience.

HSE, Health Services Executive.

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process and aid critical reflexivity where necessary (Gobo et al., 2004; Holloway and Wheeler, 2009). The emergent themes from all transcripts were analysed to elicit primary themes and sub-themes (Table 2), thus forming the basis for the following findings.


primarily time and a lack of professional skills to source and appraise research evidence in the arena: ‘So you don’t have the time to be able to go and research, except when it’s on your own time … but if it was accessible to you, if it was there and you could say “oh right, I can look at this, this and this, all done and sorted”, you would pull it’. (Lynn)

Four primary themes and a number of sub-themes emerged from analysis of the data (Table 2).

It is noteworthy, however, that the majority of participants cited having supportive logistic resources to enable the attainment of evidence-based knowledge on VR, including access to library and electronic database services.

Theme 1: Barriers to enacting EBP

Theme 2: Impact of educational methods used


All participants expressed feelings that OTs should be key players in VR as: ‘We are perfectly placed to do it’. (Claire) However, many challenges were reported in relation to the implementation of VR in clinical practice. The challenges described pertained to issues involving a lack of role awareness, undergraduate training, managerial support, resources and confidence: ‘It was a very daunting area to look at and you did feel that you needed to have more training’. (Jane) Barriers were also expressed in relation to the implementation of EBP. These related to resource issues,

(a) Impact on clinical practice All participants reported the educational initiative to be a positive experience and of clinical benefit, although to varying degrees. In regard to the PEM shared, all expressed a direct benefit in terms of confidence and knowledge: ‘I felt that every OT should have it on their shelf, to be honest. It is definitely very good … It gives confidence’. (Emma) A change in practice behaviours as a result of the exchange was voiced by all, with the greatest change appearing to occur for those less experienced in the field of VR. Practice behaviours that underwent change included a tendency to ask the work question in a more detailed way; the use of

Table 2. Themes Primary theme Barriers to enacting EBP in relation to VR

Impact of educational methods used

Methods of improving knowledge translation for future learning needs Educational strategies to contribute to the development of occupational therapy-led VR services in Ireland

Sub-theme Professional, system and resource barriers to the implementation of VR practices in the present Irish healthcare context Challenges for occupational therapists in the implementation of EBP in relation to VR Degree of change incurred in VR practice behaviours Benefit of attaining printed education material in the guidebook format Impact of teleconference and peer exchange forum Impact of email/telephone support Increased opportunity for peer exchange with an expert in the field Enhanced use of interactive learning methods Establishment of a peer support/learning group affiliated to the AOTI Implementation of occupational therapy-led VR programmes and undertaking research to demonstrate effectiveness Promote VR as a recognized core work domain for occupational therapists at strategic and national levels

AOTI, Association of Occupational Therapists in Ireland; EBP, evidence-based practice; VR, vocational rehabilitation.


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standardized outcome measures; and the tendency and confidence to undertake employer liaison: ‘It [work] was always on my initial assessment … but I wouldn’t always ask it. I would often make assumptions’. (Jane) For those more expert in the field, an overt change in practice behaviours was not expressed; however, a sense of affirmation and a tendency to revisit practice behaviours was: ‘It was useful because it reassured me … it reminded me of tools and techniques of which I was aware but had not implemented for some time’. (Emma) The primary educational method of PEM (guidebook) was cited as a format of benefit for a variety of reasons, including that it was easy to read; collated evidence-based information specific to occupational therapy; used simple diagrams and case examples to represent processes of intervention; and was easy to share with colleagues and patients without resource implication: ‘I find having paper documentation helpful and I think that it also gives the patients confidence as well … It’s quick and accessible. It’s easy to use. It has evidence behind it and it’s applicable’. (Lynn) (a) Impact of adjunct educational methods In regard to the adjunct methods (introductory teleconference and email/telephone support) used in this educational exchange, the findings were variable. While no participant utilized the opportunity to engage in the telephone or email support mechanism offered, all reported a common notion that it was ‘reassuring’ (Claire) and instilled increased confidence to know that it was available. In regard to the benefit of the initial group teleconference, variability in the perception of benefit correlated with the level of experience that participants felt they had in VR. Those who had a degree of experience in VR expressed benefit in relation to peer exchange and guidance. One participant expressed an alternative view, however, in that the introductory exchange did not meet her level of learning need, suggesting a mismatch in levels of VR experience within the group as a challenge to this: Musculoskelet. Care 12 (2014) 118–124 © 2013 John Wiley & Sons, Ltd.

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‘I don’t know, maybe even one-on-one, probably would have been better … probably just maybe I wasn’t getting exactly what I needed out of it’. (Claire) Theme 3: Methods of improving knowledge translation A commonality was noted from all of the participants regarding the integration of more interactive learning forums to enhance outcome. Having a forum for shared exchange with expert peers was cited by most as necessary to ensure improved transfer of knowledge in the future: ‘Just the things that I remember and I’ve learnt are usually because I remember somebody experienced in the area saying this’. (Jane) Theme 4: Educational strategies to contribute to the development of occupational therapy-led VR services in Ireland The final theme pertains to educational strategies that may be implemented to progress the integration of VR into the standard role of the OT in the Irish context. These relate to the establishment of VR as a learning objective on undergraduate curricula and the implementation of interactive workshops to facilitate learning with expert peers: ‘We don’t have enough case study-type workshops … an OT advisory group in VR is essential, I feel’. (Emma) Most participants also described the necessity of demonstrating evidence in the field at national and strategic level and viewed this as essential for professional development in the field of VR.

Discussion All participants strongly agreed that OTs need to be proactive in terms of VR, revisit their fundamental skills and reassert themselves as key leaders in the field of VR (Alsop, 2004; Bade and Eckert, 2008; College of Occupational Therapists, 2008; Lee and Kielhofner, 2009; World Federation of Occupational Therapists, 2012). A lack of system supports (relating to management, professional organization, legislative backing) was cited as a primary barrier to the integration of EBP and VR in daily clinical practice. These findings echo the literature, which describes a lack of macro121

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system supports as posing a significant barrier to EBP and knowledge translation for allied health professionals in developing areas of practice (McCluskey, 2003; Metzler and Metz, 2010). A lack of time, ability to appraise evidence critically and source profession-specific literature were all cited as specific barriers to EBP. These correlate with evidence from surveys and reports which identify the barriers commonly experienced by OTs in relation to EBP and the translation of knowledge to practice (Bennett et al., 2003; McCluskey, 2003; Law et al., 2004).

Educational strategies to promote knowledge translation in the field of VR The findings reveal all participants to have perceived a benefit in their professional practices from the knowledge exchange methods used in the present study. The format of PEM was noted by all as a beneficial educational strategy due to the opportunity it afforded to access, read and share material conveniently, without resource implication. This finds resonance with the results of systematic reviews which have found PEM, and summaries of evidence, to result in improved process outcomes for health professionals (Grimshaw et al., 2004; Farmer et al., 2008; Hakkennes and Dodd, 2008; Lin et al., 2010; Metzler and Metz, 2010). Yet, as demonstrated in other systematic reviews, focusing on evidence dissemination alone may improve professional process but it may not inherently transfer to patient outcome (Grimshaw et al., 2001; Prior et al., 2008; van der Wees et al., 2008). Therefore, it is interesting to note, from the qualitative perceptions of these participants, that they all perceived a change in practice behaviours to have occurred, albeit to varying degrees. The impact of a multi-faceted educational approach (introductory teleconference with expert peer and availability of email/telephone support) may have bolstered the outcome in the present study. All participants reported benefit from the opportunity to liaise with an expert peer and to engage in interactive peer exchange. Although debate persists, certain systematic reviews indicate that, in relation to clinical guidelines, singular knowledge dissemination strategies may be more effective when combined with interactive multi-faceted strategies (Grimshaw et al., 2001; Prior et al., 2008; van der Wees et al., 2008). This includes those using an opinion leader (Flodgren et al., 2011) and educational outreach (O’Brien et al., 2007), which the present study offered. 122

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It is also noteworthy that one participant expressed a notion that the group meeting did not fulfil her specific learning needs and suggested a one-to-one method of exchange. This alludes to adult education theory and recommendations that learners’ needs should be assessed and the education methods tailored accordingly to allow for effective knowledge exchange (Knowles et al., 1998; Bryan et al., 2009; McGrath, 2009).

Implications for allied health professionals and the development of VR services The findings of the present study correlate with those in the literature, in confirming that knowledge translation is a complex process for which there is no easy solution (Grol and Wensing, 2004; Grol et al., 2007; Lencucha et al., 2007; Metzler and Metz, 2010; Stergiou-Kita, 2010). It is clear that for this group of OTs, as in the literature, there are many barriers to the process of knowledge translation (Michie et al., 2005) and to the integration of EBP (McCluskey and Cusick, 2002; Lee and Kielhofner, 2009; Murphy and Robinson, 2010). Therefore, it is integral that, prior to undertaking knowledge translation initiatives, the barriers and learning needs of the healthcare profession in question are assessed (Grimshaw et al., 2004; Hakkennes and Dodd, 2008). In the present study, the specific learning needs of the participants were not assessed and that may have reduced the benefit for all. This group of participants voiced the need for support to progress further learning and development in the area of VR. Broader system supports have been recommended in the literature as a necessary strategy to assist knowledge translation for allied health professions (Francke et al., 2008; Metzler and Metz, 2010; Stergiou-Kita, 2010).

Limitations A number of limitations were inherent to the present study. The time frame of eight weeks was limiting in regard to the ability of participants to assess for sustained change in practice behaviours or outcome; however, a longitudinal study was outside the capability of this research project. Evaluation of knowledge exchange initiatives in healthcare from a patient perspective is also recommended (Grimshaw et al., 2004; Hakkennes and Dodd, 2008; Prior et al., 2008) and may have added to the depth of the present study, but was outside the present study’s parameters. Musculoskelet. Care 12 (2014) 118–124 © 2013 John Wiley & Sons, Ltd.

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Conclusion VR should be a key intervention in the field of therapeutic healthcare, yet there are challenges to the integration of VR practices into the standard role of OTs. Utilizing optimal methods of knowledge translation to influence a change in practice behaviour in pressured economic and clinical contexts is essential. The present study demonstrated evidence-based PEM, combined with supported interactive learning with expert peers, as an effective and preferred knowledge translation method. REFERENCES Adam K, Gibson E, Lyle A, Strong J (2010). Development of roles for occupational therapists and physiotherapists in work related practice: An Australian perspective. Work 36: 263–72. Alsop A (2004). Work matters (Editorial). British Journal of Occupational Therapy 67(12): 525. Bade S, Eckert J (2008). Occupational therapists’ critical value in work rehabilitation and ergonomics. Work 31 (1): 101–11. Bennett S, Bennett JW (2000). The process of evidencebased practice in occupational therapy: Informing clinical decisions. Australian Occupational Therapy Journal 47(4): 171–80. Bennett S, Tooth L, McKenna K, Rodger S, Strong J, Ziviani J, Mickan S, Gibson L (2003). Perceptions of evidence based practice: A survey of Australian occupational therapists. Australian Occupational Therapy Journal 50(1): 13–22. Bevan S, Quadrello T, McGee R, Mahdon M, Vovrovsky A, Barham L (2009a). Fit for Work? Musculoskeletal Disorders in the European Workforce. London: The Work Foundation. Bevan, S, McGee, R, Quadrello, T (2009b). Fit For Work? Musculoskeletal Disorders and the Irish Labour Market. London: The Work Foundation. Braun V, Clarke V (2006). Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77–101. Briand C, Durand MJ, St-Arnaud L, Corbiere M (2008). How well do return-to-work interventions for musculoskeletal conditions address the multi-causality of work disability? Journal of Occupational Rehabilitation 18(2): 207–17. Bryan R, Kreuter M, Brownson R (2009). Integrating adult learning principles into training for public health practice. Health Promotion Practice 10(4): 557–63. Caldwell E, Whitehead M, Fleming J, Moes L (2008). Evidence-based practice in everyday clinical practice: Strategies for change in a tertiary occupational therapy department. Australian Occupational Therapy Journal 55(2): 79–84. Musculoskelet. Care 12 (2014) 118–124 © 2013 John Wiley & Sons, Ltd.

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Vocational rehabilitation and occupational therapy: impact of a knowledge translation initiative.

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