title: A formative evaluation of the implementation of an upper limb stroke rehabilitation intervention in clinical practice: a qualitative interview study.
abstract: BACKGROUND
  The Graded Repetitive Arm Supplementary Program (GRASP) is a hand and arm exercise programme designed to increase the intensity of exercise achieved in inpatient stroke rehabilitation. GRASP was shown to be effective in a randomised controlled trial in 2009 and has since experienced unusually rapid uptake into clinical practice. The aim of this study was to conduct a formative evaluation of the implementation of GRASP to inform the development and implementation of a similar intervention in the United Kingdom.
  
  
  METHODS
  Semi-structured interviews were conducted with therapists who were involved in implementing GRASP at their work site, or who had experience of using GRASP. Normalisation Process Theory (NPT), a sociological theory used to explore the processes of embedding innovations in practice, was used to develop an interview guide. Intervention components outlined within the GRASP Guideline Manual were used to develop prompts to explore how therapists use GRASP in practice. Interview transcripts were analysed using a coding frame based on implementation theory.
  
  
  RESULTS
  Twenty interviews were conducted across eight sites in British Columbia Canada. Therapists identified informal networks and the free online availability of GRASP as key factors in finding out about the intervention. All therapists reported positive opinions about the value of GRASP. At all sites, therapists identified individuals who advocated for the use of GRASP, and in six of the eight sites this was the practice leader or senior therapist. Rehabilitation assistants were identified as instrumental in delivering GRASP in almost all sites as they were responsible for organising the GRASP equipment and assisting patients using GRASP. Almost all intervention components were found to be adapted to some degree when used in clinical practice; coverage was wider, the content adapted, and the dose, when monitored, was less.
  
  
  CONCLUSIONS
  Although GRASP has translated into clinical practice, it is not always used in the way in which it was shown to be effective. This formative evaluation has informed the development of a novel intervention which aims to bridge this evidence-practice gap in upper limb rehabilitation after stroke.
authors.affiliation: Clinical Practice Research Unit, School of Health, University of Central Lancashire, Preston PR1 2HE, UK. laconnell@uclan.ac.uk.
authors.forename: Louise A
authors.initials: LA
authors.lastname: Connell
authors.forename: Naoimh E
authors.initials: NE
authors.lastname: McMahon
authors.forename: Jocelyn E
authors.initials: JE
authors.lastname: Harris
authors.forename: Caroline L
authors.initials: CL
authors.lastname: Watkins
authors.forename: Janice J
authors.initials: JJ
authors.lastname: Eng
mesh_terms: D001132:Arm; D001955:British Columbia; D004059:Diffusion of Innovation; D006801:Humans; D007407:Interviews as Topic; D009788:Occupational Therapy; D026741:Physical Therapy Modalities; D010818:Practice Patterns, Physicians'; D036301:Qualitative Research; D020521:Stroke / Q000208:ethnology*
references.citation: Implement Sci. 2012 Mar 22;7:23
references.pmid: 22436121
references.citation: Implement Sci. 2013 Mar 14;8:31
references.pmid: 23497502
references.citation: Clin Rehabil. 2001 Feb;15(1):20-31
references.pmid: 11237158
references.citation: Implement Sci. 2013 Sep 05;8:102
references.pmid: 24006959
references.citation: Clin Rehabil. 2004 Dec;18(8):833-62
references.pmid: 15609840
references.citation: Implement Sci. 2014 Jan 17;9:14
references.pmid: 24438584
references.citation: Implement Sci. 2007 Nov 30;2:40
references.pmid: 18053122
references.citation: Implement Sci. 2013 Aug 26;8:97
references.pmid: 23972055
references.citation: BMC Med Res Methodol. 2014 Mar 10;14:38
references.pmid: 24606877
references.citation: Implement Sci. 2013 Mar 23;8:35
references.pmid: 23522377
references.citation: Lancet Neurol. 2009 Aug;8(8):741-54
references.pmid: 19608100
references.citation: BMC Health Serv Res. 2013 Aug 19;13:323
references.pmid: 23958136
references.citation: Milbank Q. 2004;82(4):581-629
references.pmid: 15595944
references.citation: Implement Sci. 2013 May 10;8:51
references.pmid: 23663819
references.citation: Cochrane Database Syst Rev. 2012 Jun 13;(6):CD000259
references.pmid: 22696318
references.citation: Implement Sci. 2010 Sep 03;5:67
references.pmid: 20815872
references.citation: BMJ. 2004 Oct 30;329(7473):1013
references.pmid: 15514347
references.citation: Arch Phys Med Rehabil. 2009 Oct;90(10):1692-8
references.pmid: 19801058
references.citation: Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003030
references.pmid: 19370580
references.citation: J Neurol Phys Ther. 2007 Mar;31(1):3-10
references.pmid: 17419883
references.citation: Qual Health Res. 2005 Nov;15(9):1277-88
references.pmid: 16204405
references.citation: Early Child Res Q. 2010;25(3):270-283
references.pmid: 21103189
references.citation: J Rehabil Med. 2014 Mar;46(3):212-8
references.pmid: 24473633
references.citation: Implement Sci. 2014 Jan 02;9:2
references.pmid: 24383661
references.citation: Phys Ther. 2014 May;94(5):632-43
references.pmid: 24505098
references.citation: Implement Sci. 2013 Aug 23;8:96
references.pmid: 23972027
references.citation: Cochrane Database Syst Rev. 2012 Oct 17;10:CD004398
references.pmid: 23076904
references.citation: Implement Sci. 2009 Aug 07;4:50
references.pmid: 19664226
references.citation: Cochrane Database Syst Rev. 2012 Dec 12;12:CD001175
references.pmid: 23235578
references.citation: J Gen Intern Med. 2006 Feb;21 Suppl 2:S1-8
references.pmid: 16637954
references.citation: Implement Sci. 2013 Sep 08;8:107
references.pmid: 24010732
references.citation: PLoS One. 2014 Feb 04;9(2):e87987
references.pmid: 24505342
references.citation: Stroke. 2009 Apr;40(4):e89-97
references.pmid: 19182079
references.citation: Stroke. 2009 Jun;40(6):2123-8
references.pmid: 19359633