https://orcid.org/0000-0002-8588-5367
ABSTRACT
Background
The Hypertonicity Intervention Planning Model (HIPM) is a decision-making aid which guides clinical reasoning in individualizing upper limb (UL) neurorehabilitation.
Aim
To examine the HIPM’s clinical utility across cultures, using therapists’ perceptions of its usefulness and challenges when applied in clinical practice.
Methods
Interpretive description methodology guided qualitative data collection and analysis because it produces clinically practical applications. Forty-four occupational therapists working in Australia or Singapore participated. Three group discussions were conducted using a modified nominal group technique.
Results
Three themes were: (1) The HIPM guides systematic clinical decision-making for assessment, goal-setting, and intervention; (2) Utility was influenced by systemic or organizational supports and barriers including availability of time, resources, and funding; organizational readiness to change; multidisciplinary and transorganizational collaboration; (3) Therapists’ skills and confidence to apply the HIPM, and openness to changing practice, influenced utility.
Conclusions
Therapists strongly support HIPM use for structuring and communicating clinical reasoning in UL neurorehabilitation. However, organizational support is key to optimizing clinical utility. Incorporating decision-making aids into documentation and referral processes may strengthen multidisciplinary and transorganizational teamwork, enhancing clinical use. Different training tiers to suit therapist experience levels, refresher courses, and supplementary resources may improve therapists’ skills and confidence, thereby boosting utility.
Introduction
People with neurological conditions such as stroke, traumatic brain injury, and cerebral palsy commonly experience upper limb (UL) impairments such as weakness, loss of voluntary movement, altered sensation, and hypertonicity (Citation1). Hypertonicity is an increase in muscle tone, characterized by greater than expected stiffness or resistance during passive lengthening of soft tissues around a joint (Citation2). Participation in daily tasks requiring controlled UL movement is negatively impacted by hypertonicity (Citation3). UL neurological rehabilitation aims to promote re-engagement in daily tasks, but is complex because each client presents with a unique combination of UL characteristics contributing to movement dysfunction (Citation3,Citation4).
Intervention techniques focused on restoring UL function include constraint-induced movement therapy (CIMT), mental practice, mirror therapy, virtual reality, and repetitive task-specific training (Citation1,Citation5). Despite growing research evidence of the effectiveness of individual techniques, research alone provides limited guidance about when and for whom each intervention is appropriate (Citation6,Citation7). In making intervention decisions, occupational therapists consider the client’s UL impairments and contextual factors such as their social supports and living situation, past UL interventions trialed and their outcomes, practice constraints, resources and funding available, and the therapist’s professional skills and experience (Citation8). This decision-making process utilizes clinical reasoning, whereby therapists integrate experiential and theoretical knowledge with clinical data, client choices, and various contextual factors to achieve distinct rehabilitation goals for each client (Citation9,Citation10). Due to the diversity of client presentation and the range of UL intervention techniques available, therapists have long expressed a need for guidance in structuring the clinical reasoning process in UL neurorehabilitation (Citation6,Citation11).
Decision-making aids guide clinicians to organize information about client characteristics and contexts, and link this to step-by-step decisions to facilitate clinical reasoning. This could make them particularly useful in managing the complexity of UL neurorehabilitation (Citation4,Citation10). Such aids often take the form of algorithms, frameworks, or clinical protocols (Citation12), and provide direction regarding factors to consider during assessment, which are then stratified and linked to intervention recommendations (Citation10). This differs from evidence-based clinical guidelines, which typically offer only generalized recommendations about the use of UL intervention techniques.
A recent scoping review found 15 decision-making aids for UL interventions in neurological rehabilitation (Citation12). Consultation with an expert panel of occupational therapists identified the Hypertonicity Intervention Planning Model (HIPM) (Citation4) as a potentially clinically useful decision-making aid for individualizing UL neurorehabilitation in the presence of hypertonicity. First published in 1999 (Citation13), the revised HIPM version was published in a neurorehabilitation textbook in 2014 (Citation4). Appendix I illustrates the HIPM, which guides clinicians to assess specific aspects of clients’ UL impairments and function, classifies these into 1 of 4 categories (HIPM 1, 2a, 2b, 3), and suggests clinical aims and primary and secondary intervention options for each category. Intervention categories include strength and movement training (which encompasses a broad range of specific techniques such as repetitive task-specific practice, mirror therapy, functional electrical stimulation and so on), splinting, casting, Botulinum toxin-A injections, and surgery.
Although the HIPM was identified as a promising decision-making aid for neurorehabilitation, authors suggested that targeted training is vital for clinicians to use decision-making aids effectively and reliably (Citation12). Targeted training facilitates healthcare professionals to apply clinical guidelines and translate knowledge into practice (Citation14). This is particularly important when clinicians need to skillfully collect, interpret and integrate many types of information to make well-informed, individualized decisions in complex areas of practice such as UL neurorehabilitation. Training in use of either the current or original version of the HIPM has been conducted since 2003, either through mentorship and supervised practice by the HIPM’s developers, or through continuing professional development (CPD) workshops in several countries including Australia, Canada, Singapore, United Kingdom, and the United States of America.
After training in the HIPM, novice therapists’ clinical reasoning more closely reflected the content and structure of expert therapists’ reasoning (Citation15). Expert therapists also demonstrated improved client-therapist collaboration in case study scenarios, and better discrimination of more subtle features of the client’s UL status and personal context to inform decision-making (Citation15). However, it remained unknown whether therapists found it useful or challenging to apply in practice. Evidence of the HIPM’s clinical utility — defined as a systematic assessment of a tool or intervention’s usefulness, benefits, and drawbacks (Citation16) — is required. Specifically, authors were interested in examining how and in what ways the HIPM was useful, and the challenges faced when implementing it in practice. Therefore, this study aimed to examine the cross-cultural clinical utility of the HIPM after targeted training.
Methods
An established approach for applied qualitative health research, interpretive description guided participant sampling, data collection, and analysis (Citation17). Interpretive description recognizes the complex, contextual, and constructed nature of human experience. It also simultaneously allows for shared realities among participants in similar situations (Citation17), who, in this study, are therapists who had used the HIPM in clinical practice. Interpretive description draws on subjective experiences to understand common patterns within clinical phenomena in practice-based disciplines, the implications of which can then be applied in everyday practice (Citation17). In accordance with the study aim and the interpretive description approach (Citation17,Citation18), purposeful sampling was employed to solicit data from a representative range of therapists who had varying levels of experience with using the HIPM.
In interpretive description, understanding experiences in each participant’s specific context is essential for improvements to practice (Citation17). Nominal group technique involves structured brainstorming where participants individually generate and record ideas to pre-determined questions, before prioritizing and discussing these ideas in a group (Citation19). This study used a modified nominal group technique (19 to gather participants’ perceptions of the usefulness and challenges of applying the HIPM in clinical practice, as it provides a systematic way of ensuring that all perspectives in the group are captured. Ethical approval was obtained through The University of Queensland Human Research and Ethics Committee (approval number 2018000509).
Setting and participants
Participant sampling was purposive to represent therapists in two different countries (Australia and Singapore) who had received prior training in the HIPM, and who collectively worked with a diverse range of clients with neurological conditions causing UL hypertonicity across various settings (hospitals, schools, community). However, participant sampling was also convenient as recruitment was done through health services that had organized past HIPM training for their own and/or external occupational therapists. This targeted training occurred in the form of a 3-day workshop delivered face-to-face by a developer of the HIPM. It covered assessment and decision making using the HIPM with clinical scenarios, as well as implementation of key interventions, including practical splinting and casting sessions.
Participants were eligible for inclusion in the study if they were occupational therapists working with clients with acquired or congenital brain injury. They must have already completed training in the HIPM, either by the HIPM developers or by trained therapists in their workplace. Signed informed consent was obtained.
Forty-four occupational therapists participated across three discussion groups. Participant demographics are summarized in .
Table 1. Participant demographics.
Data collection
Group discussions were conducted by AT and JC, immediately after a professional development refresher session on the HIPM. In formulating the size and nature of participant groups, a pragmatic approach was taken to fit in with participant availability, resulting in different group sizes. Details of each group discussion are in . The online group discussions with participants in Singapore [G2, G3] lasted longer than the group discussion [G1] in Australia due to the online format, where more time was needed to gather input from all participants.
Table 2. Details of each group discussion.
Before the group discussion, all participants independently completed a written questionnaire asking the following open-ended questions: ‘Thinking about applying the HIPM when working with your clients, 1) What have you found useful? 2) What have you found challenging?’ In accordance with the nominal group technique, questionnaire responses were then categorized and prioritized to identify key ideas for elaboration in the group discussion. However, the format taken for the prioritization of ideas differed slightly between the in-person [G1] and online groups [G2, G3] due to differences in group size and nature. Participants in G1 shared their individual responses in small teams of 4–5 participants. Then, each team identified their top two most useful and most challenging aspects of the HIPM, which were used to guide the G1 discussion. As for G1, the online groups [G2, G3] participants’ most common responses about both the useful and challenging aspects of the HIPM were shared, and guided each respective group discussion. However, as online participants were participating remotely and could not meet in small teams of 4–5 participants (as in G1), their questionnaire responses were compiled and shared by AT in order of frequency.
Online group participants were also invited to provide case study information prior to the refresher session using a template based on the HIPM. This served three purposes: 1) The Australian group had in-person discussion of cases during their professional development refresher session to prepare them for the group discussion, hence the Singaporean groups were asked to provide cases to facilitate them to think specifically about applying the HIPM in their culture and context; 2) To engage Singaporean group participants in the online format; and 3) These case study templates offered in-depth examples about how participants had applied the HIPM with their clients after the original HIPM training, which was seen to be useful as a supplementary source of data collection.
Data analysis
Group discussions were audiotaped and transcribed verbatim by AT. Free text questionnaire responses and transcripts were analyzed thematically using interpretive description (Citation17). Points of comparison and contrast between Singaporean and Australian data were intentionally sought. Two researchers [AT and JC] independently generated inductive codes from G1 participants’ individual questionnaire responses. Both researchers met to resolve differences and generated a common coding framework which they applied independently to the G1 transcript. They again identified and resolved discrepancies, resulting in an updated coding framework which AT applied to data from G2. No new codes were generated as the data from G2 was fully represented by the coding framework. After two further meetings to clarify minor uncertainties in coding, AT applied a final coding framework to all data. To check definitions for each code, JF applied the final coding framework to one transcript [G3]. No new codes emerged, and existing codes were combined to generate key themes. Peer checking and constant comparison (Citation20) occurred at multiple stages throughout and contributed to the revision of themes, until consensus was reached. Transcripts were also repeatedly reexamined as themes were identified and clarified, to ensure that they were grounded in the data. Between Singaporean and Australian data, no dissimilar themes emerged, indicating no cultural differences between both countries in applying the HIPM.
Member checking was done to encourage elaboration and clarification of researchers’ inductive interpretations. Participants were given a summary of the analysis to check and make further comments. Fourteen participants (31.8%) responded, confirming that it represented their thoughts, and one added more detail.
Five case studies demonstrating application of the HIPM were received from participants in the online groups [G2, G3] as part of the professional development refresher session prior to the group discussion. These case studies were reviewed by JC, an expert therapist in UL neurorehabilitation and one of the developers of the HIPM. The first author (AT) conducted content analysis to compare the application of the HIPM on these case studies between participants and JC. This informed interpretation of the group discussion data, as they provided a snapshot of how some participants had been applying the HIPM.
Researcher reflexivity
The research team consisted of three occupational therapists, two of whom had extensive experience in neurorehabilitation research. JC was one of the developers of the HIPM, and conducted short CPD sessions as an incentive for participants to attend group discussions. However, researchers intentionally encouraged critical feedback on the challenges of applying the HIPM in practice, highlighting our intention to improve the HIPM and its clinical utility. Participants appeared comfortable to provide their perspectives on the challenges of using the decision-making aid, as they were open in highlighting these challenges across all three group discussions. Throughout the data collection process, researchers documented personal reflexivity notes to record their personal reactions and influence of their perspectives and experiences on their reactions.
Results
Data analysis resulted in a single set of themes being generated across both countries. No divergent themes were found that applied to either cultural setting. The three themes consistent across both countries related to the usefulness and challenges of applying the HIPM in clinical practice: (1) A systematic approach to clinical decision-making; (2) Systemic or organizational supports and barriers; (3) Therapist factors affecting HIPM use. Key findings are reported using pseudonyms for representative quotes.
A systematic approach to clinical decision-making
Across all group discussions, a strong theme was the usefulness of the HIPM as a systematic approach to clinical decision-making, particularly in guiding therapists’ clinical reasoning throughout the assessment and intervention process. For example, participants appreciated that the HIPM is ‘very structured and step-by-step’ (Ellie, G2), and helps ‘guide where to even start’ (Amy, G1).
I see the HIPM as helping me to guide the clinical reasoning, in terms of like, Where is the patient now? What should I look out for? What intervention? (Sheila, G3)
Participants reported that the HIPM facilitated comprehensive assessment of the UL and helped them identify specific aspects of UL function which informed their clinical aims and led to collaborative and realistic goal-setting with the client. In particular, the HIPM’s classification of clients into four categories provided a clear clinical picture of where the client fits along the spectrum of UL function. They liked that each category then linked to a group of recommended UL interventions.
I found it quite easy to use the HIPM to classify upper limb interventions because you kind of know what symptoms to look out for in HIPM 1, 2, and 3. So that triggers also then, the thought processes of, what is the next step that you need to do, which is identify the symptoms, and after that, what interventions you need to kind of look into, and deciding which is the best for the patient. (Serene, G2)
The HIPM was also described as a useful tool for facilitating communication with clients, other occupational therapists, and other healthcare professionals in the multidisciplinary team. It allowed therapists to use a common language, helped them educate clients and caregivers about their clinical reasoning process and justify their intervention choices, and sometimes provided a framework for documentation.
We were talking through, “OK this is what I can see” and he [the client] was like “Oh yeah I notice that too.” I found that the HIPM helped helped him work through the justification as to why we would look at going down a particular road. So, it almost helped him categorize himself, so it was almost like a tool that we used together, to really look at a systematic approach to A + B = C … (Bianca, G1)
I will write down HIPM what level … if we share patients then I think that is helpful. [colleague] straightaway understands what I’m talking about and so, we are on the same page. So, I think it also facilitates that clinical handover across therapists (Sheila, G3).
Systemic or organizational supports and barriers
Despite the advantages of using the HIPM for clinical reasoning, systemic and organizational supports and barriers were frequently highlighted by participants from both countries as factors affecting its clinical utility. Most participants discussed the limited availability of resources, time, and/or funding within the organization and healthcare system as a barrier to using the HIPM in practice. Resources that affected participants’ ability to implement the interventions suggested by the HIPM included the availability of materials for splinting and casting, a conducive space for interventions to be delivered, and existing organizational expertise for interventions such as casting. Although participants found the HIPM’s comprehensive assessment and goal-setting process beneficial for their clients, it was time-consuming and difficult to manage within busy caseloads. Participants also needed more time to work through a new decision-making aid. Clients’ limited funds for therapy sometimes made it challenging for participants to be able to implement HIPM interventions for UL management, particularly when the client also had ‘a bundle of other priorities that might need to be met around assistive technology and seating’ (Kayla, G1).
Beyond the availability of resources, the organization’s readiness to change their service provision practices to support use of the HIPM and its interventions also affected the application of the HIPM in practice. Therapists working in organizations which had not previously offered casting and splinting sometimes faced resistance when trying to set up these new services, because the organization ‘would rather refer it out’ (Beth, G2)
It’s also how open is the organization that you’re working with … they might have their own sets of forms, or way of assessment or treatment. So, it’s the whole team approach as well. So, it might be a challenge there (Beth, G2).
In contrast, organizations that were willing to set up new services, provide resources and training for these interventions, and change their referral and documentation processes facilitated participants to more consistently and frequently apply the HIPM in practice.
We set up the OT [occupational therapy] casting clinic. [As] part of choosing the patients for casting, we also need to report what is the HIPM level, and what is the progress like. So, we actually put it down as something that we need to do as part of the workflow for the OT casting clinic (Sabrina, G3).
Varied levels of teamwork and collaboration within and across disciplines were reported across organizations. Most participants expressed that disciplines outside occupational therapy lacked awareness of the HIPM. Insufficient collaboration from the medical team also limited use of the HIPM to choose goal-directed interventions. This was particularly the case for therapists working in the community, where clients may only be referred to them after interventions were decided by a medical team, without therapist input.
This client comes in “yes, I’m booked in for the Botox and the casting” and that’s the given decision! And then we go like, “O-kay? [pitch rises] Why? What? How?” … Sometimes they come out of medical appointments, with the path already given … with not necessarily that reasoning given to us (Vicky, G1).
We’re not involved in that decision-making process for the surgery. We might know it’s happening but … not told why or what the functional goals are… Maybe if there was a functional goal for surgery, we could help tie that picture together. But often it’s just surgery and then we have to come up with a goal afterwards (Kelly, G1).
Some organizations took a different approach of incorporating the HIPM into their routine processes and using it as a common framework for the whole team. Participants in these organizations found the HIPM useful for discussing and handing over clients to other therapists. Strong multidisciplinary partnerships involving ongoing communication to deliver interventions such as casting also facilitated more consistent use of HIPM.
With the more experienced doctors, yes, the collaboration has always been there. So, communication has been quite tight. But when it comes to the junior doctors, it’s always a continuous engagement to tell them how spasticity can be better managed and not just through Botox (Serene, G2).
Participants highlighted problems with teamwork across organizations and sectors in both Australia and Singapore. For example, limited communication between tertiary hospitals and community services was commonly raised as a challenge to applying the HIPM in practice. To improve utility of the HIPM, participants suggested that organizations should incorporate the tool into their routine processes and create consistent processes for collaboration and referrals across multiple organizations.
Therapist factors affecting HIPM use
Beyond the broader systemic and organizational contexts, many participants identified personal and individual reasons that limited their use of the HIPM, including reduced confidence, knowledge, and skills in using the aid and its recommended interventions. Several participants expressed lacking confidence or skills to complete the HIPM’s assessment process in a timely manner, or to identify positive and negative features when analyzing client function. Others struggled with the technical skills and knowledge to successfully apply interventions like casting or splinting.
Initially, I wanted to look into all the components, which is positive, which is negative. It took me a long time to look in all the nitty gritty different joints, and all the different range of movement (Ellie, G2).
For the finer details, like deciding on the functional splint design and all that, I still find HIPM useful but it’s still quite difficult for me to use it, unless I really try to focus a lot on the positive and negative symptoms… that part is still a little bit confusing sometimes (Sabrina, G3).
Review of the case study templates completed by five participants in G2 and G3 illustrated this challenge for some participants in applying the HIPM in a detailed way. For example, compared with the information which the expert therapist (JC) identified from the case studies, these participants had not recorded all the specific muscle groups that had showed hypertonicity or contracture. These participants also had difficulty describing details of the client’s reach and grasp patterns, including the relative position of the wrist, fingers, and thumb position during grasp and release. Intervention decisions were generally appropriate for addressing the identified clinical aims, but did not always include details about the ways in which the intervention would be specifically applied e.g., the type of cast or splint and the position of the hand.
Some participants described that with practice, using the HIPM took less time, and their ability to make more specific and tailored decisions improved. For others, reduced confidence and skills were often related to a lack of opportunity for practical experience in applying the HIPM, usually due the absence of suitable clients within their caseload. They recognized that if they had ‘a chance to do it [on a] daily basis, maybe it will be much faster’ (Ellie, G2).
When you don’t use [the HIPM], you don’t feel confident in using it (Fiona, G3).
Therapists’ openness to changing their usual practices also influenced HIPM use. Some participants admitted that they sometimes knew what ought to be done according to the HIPM, but did not follow through with the recommended process or interventions in practice, as this required setting up new services. For instance, participants found it time consuming and tedious to organize ‘costings and the equipment set-up’ (Marilyn, G2).
Sometimes when I see a hypertonicity, especially if it’s a [HIPM] Group 3 kind of patient, I know that splinting might not cut it, but casting might be it. But I’ve just never had the courage to start this ball rolling (Marilyn, G2).
Time constraints also meant participants often stuck to their usual routine practices instead of following the HIPM processes.
We do not see our patients that often (once in 1–2 months), and once we do see them, we feel like we have to focus on intervention/ strength and movement training in the session. We might not spend enough time actually assessing and finding out specifically what’s the problem with specific muscle groups (Valerie, G3).
Participants offered many suggestions to improve therapists’ confidence, knowledge, and skills in using the HIPM. Although participants valued the training provided through introductory HIPM workshops, they suggested multiple stages of training targeted according to therapist experience level. Periodic refresher courses, further mentorship, and case study discussions were also proposed.
It would be useful to explore having some kind of online training whereby we look at different hands … slowed down, maybe in greater detail … assessing some of the finer qualities of the hand movements, and then what we do with it, are we interpreting it correctly? Which is more of clinical skills, which would not come from just following a model … it comes with discussion amongst OTs [occupational therapists]. And then another level up would be mentorship, for example, if you’re really discussing with someone else who has a better eye (Fiona, G3).
Introducing the HIPM at an undergraduate level in local universities was also seen as a useful way of ensuring that future therapists had basic knowledge of the HIPM.
Participants also expressed a need for more information or supplementary reference materials and resources specific to particular assessments or each of the recommended interventions. Examples include YouTube videos of working through the HIPM with a case study example, or links to further information on specific types of strength and movement training interventions.
‘After I attended [the HIPM training], actually I want to go back and apply, but I realized that I was stuck at the assessment … I went to YouTube … but I couldn’t really find. So that’s why I was thinking, if I can have the chance to watch how you do it, it would be very helpful (Ellie, G2).
Different formats of the HIPM (such as a condensed version, a more pictorial version, or a more detailed version with links to supplementary materials) were also suggested to cater to different levels of therapist experience and varying purposes of using the HIPM. For example, accompanying visuals could help therapists to use the HIPM to educate clients about their UL intervention.
Most of the people we are working with … have a range of literacy levels, communication skills, cognition. And [resources, including visual exemplars] would really help … to educate them … I know that this is more for us, but it is very useful as an education tool as well. And that would make it even more useful (Amy, G1).
While not a major theme, participants also described times that client factors affected HIPM outcomes, which influenced its clinical utility. In particular, participants reported incidents whereby some clients, caregivers, or support workers faced difficulty with accepting, complying with, or following through with HIPM interventions. This could be due to negative perceptions from past intervention experiences, difficulties in client behavior and tolerance toward splints, or difficulty meeting time commitments. Consequently, this meant that clients did not always receive or complete the intervention that would be most beneficial for them according to the HIPM.
We were certainly talking about training in terms of training for support workers. So, a lot of our adult clients who might be in the [HIPM] 2b or 3 category live in supported accommodation … to get them to do any follow-up after you’ve done something like casting is a big feat. So, I think that’s one of the barriers, not to the model, but just generally, for us (Alexis, G1).
Discussion
This study sought to examine the cross-cultural clinical utility of the HIPM from the perspectives of occupational therapists who had received targeted training. Both countries provided consistent feedback about HIPM use in clinical practice. Similar points of usefulness and issues were raised, and no cultural differences specific to the application of the HIPM in their context were identified. Overall, participants in Australia and Singapore found the HIPM to be a worthwhile and helpful decision-making aid for clinical practice. This is unsurprising considering that the HIPM has several key features which were judged by expert clinicians to make UL decision-making aids particularly useful: 1) client-centered goal-setting within a holistic assessment; 2) specific intervention options that are systematically linked to distinct UL assessment results; and 3) prompts to reevaluate client performance and function (Citation12). Given that therapists have consistently expressed a need for clearer guidance in navigating clinical reasoning in UL neurorehabilitation, including what, when, or how much therapy to provide (Citation6), a decision-making aid like the HIPM may have been seen as responding to an identified gap in the guidance available to clinicians.
Across both countries, participants highlighted similar factors influencing the HIPM’s clinical utility. The HIPM’s utility in practice was supported or hindered by the influence and commitment of the organizations within which therapists work, which was largely beyond their control. This finding may be explained by knowledge translation models and frameworks (such as the Implementation Roadmap (Citation21)) which consistently emphasize the importance of assessing and addressing contextual barriers and supports relating to the practice setting when adopting changes to practice at an organizational level. Therefore, optimizing the utility of a decision-making aid like the HIPM extends beyond targeting individual therapist factors, as it works best when adopted into an organization that supports its use. There is widespread recognition that the availability of time, funding, and resources (both physical and organizational expertise) greatly influence intervention provision in rehabilitation (Citation6,Citation8). Our study findings lend further support to the importance of these factors when adopting clinical reasoning or decision-making aids to optimize intervention outcomes.
Teamwork and collaboration within and between organizations and disciplines was another factor that either facilitated or inhibited the use of the HIPM in clinical practice. Other studies have found that strong teamwork between organizations and disciplines improved multilevel outcomes in healthcare settings, ultimately enabling safer and higher quality care (Citation22,Citation23). Therefore, stroke rehabilitation guidelines often strongly recommend treatment involving a multidisciplinary team (Citation5). In our study, participants expressed a need for a consistent process for collaboration and referrals among organizations. This is supported by literature highlighting that the key dimensions of multidisciplinary teamwork include clear common goals, effective communication, shared clinical decision-making, development of joint protocols and work practices, and regular team meetings (Citation22). The organizational context was also emphasized for its importance in facilitating good teamwork (Citation22). Consequently, neurorehabilitation decision-making aids should feature strategies to strengthen multidisciplinary teamwork and collaboration (e.g., collaborative goal-setting with clients and also multidisciplinary team members), in order to enhance utility and client outcomes in practice.
Therapists’ confidence, knowledge, and skills were also key influences on the utility of the HIPM. Despite all participants attending targeted training, many – including experienced clinicians in UL neurorehabilitation – expressed challenges in either making the finer intervention decisions individualized to each client, or in executing the technical skills required in delivering casting and splinting interventions. This highlights the complexity of clinical reasoning that has often been reported in the literature (Citation8,Citation11). Therapists not only incorporate research and a wide range of client, therapist, and contextual factors into their decision-making (Citation8,Citation11), but also need to dynamically reevaluate and respond to new information to make highly specific intervention decisions tailored to each individual (Citation24–26). For example, in fabricating a custom-made wrist and hand cast, considerable expertise is required to integrate the clinical aims for the UL and the client’s therapy goals to determine the specific position of the wrist, fingers, and thumb which would provide the client with a prolonged low load stretch (Citation24,Citation25) but also be manageable for the client and caregivers. Our study found that while decision-making aids such as the HIPM can guide a therapist’s intervention decisions, they ultimately cannot replace the dynamic and rich clinical decision-making process that therapists engage in on a daily basis to make on-the-spot implementation decisions.
In order to improve knowledge, confidence, and skills in applying the HIPM, participants expressed a need for refresher courses, ongoing mentorship, and differentiated tiers of training based on therapist expertise. This is supported by research showing that active participation in professional development and knowledge transfer activities (including specialized courses and case discussion meetings) drives the development of advanced clinical reasoning and expertise in stroke rehabilitation (Citation27). Healthcare practitioners with different levels of experience and expertise are also known to have distinct training needs (Citation28). It is recommended that employers and health systems share responsibility for therapists’ professional development and training (Citation29), such as by supporting teams of therapists to be trained in using decision-making aids. This would boost therapists’ confidence in implementing the aid in practice, because they are able to learn, implement, and practice it together. We found that participants in G3 (who received HIPM training through their employer) applied the HIPM in practice more frequently compared to participants who worked in organizations where their colleagues had not been trained.
Therapists’ openness to changing usual practices also affected how much they implemented and applied what they learnt from the targeted training on the HIPM. Some participants expressed knowing that HIPM use would lead to improved client outcomes, but did not actually change their usual practice. For example, despite realizing that casting was necessary to manage a client’s hypertonicity, some chose to only prescribe a splint due to greater perceived barriers (time, resources, confidence) for casting. Such failure to translate new evidence and practice methods into clinical practice can lead to ineffective, unsafe, and costly healthcare (Citation29). Consequently, recent literature has called for CPD courses to extend beyond improving clinicians’ knowledge and move toward facilitating professional behavioral change in daily practice (Citation29–31). CPD activities should use a mixture of interactive and didactic formats, involve multiple exposures, last longer, and focus on outcomes deemed important by clinicians (Citation32). To motivate change, participants can be asked to complete commitment to change (CTC) statements (Citation33) which explicitly seek their intention to change based on the educational activity (Citation31). Furthermore, organizations should consider re-organizing service delivery to allow therapists to get more intensive practice to consolidate what they have learnt through CPD activities. This enables them to gain more confidence and comfort in modifying their practice to accommodate knowledge.
Another study finding was that clients and their carers sometimes had difficulty accepting or complying with interventions. Challenges in ensuring treatment compliance or adherence are common across health professions (Citation34). However, the HIPM tries to mitigate these challenges by requiring therapists to consider clients’ goals, and personal and environmental factors, in selecting suitable interventions (Citation4). Therapists should hold in-depth conversations with clients and their significant others to collaborate on intervention decisions, and ensure they understand the purpose of each intervention chosen and its potential benefit. Clear expectations should also be set about what each intervention will involve and how they might fit into the client’s daily life. Open communication and collaborative discussions are likely to improve clients’ compliance because social support from family and friends, intention to carry out the intervention, and intrinsic motivation are some of the strongest predictors of therapy adherence (Citation34).
Overall, our findings revealed that while the HIPM is considered a highly useful decision-making aid, its clinical utility is influenced by systemic and organizational factors, the therapist, and the client. Ultimately, these reflect the key influences in Schell’s Ecological Model of Professional Reasoning (Citation8) which posits that therapy situations are shaped by the therapist, the client, and the unique practice context within which they operate. Intentional actions from the individual therapist, the multidisciplinary team, and organizations that provide UL neurorehabilitation services appear to mitigate challenges and support its integration into practice.
Strengths, limitations, and future directions
This study provides useful insights on the complexity of applying a decision-making aid in clinical practice, and suggestions on how its clinical utility can be optimized. These insights are not limited to decision-making aids, but rather, could be applied for all clinicians seeking to apply models, theories, and frameworks that they have learnt about through CPD activities. Our study findings may also benefit future developers of decision-making aids and their trainers. Managers of organizations must recognize the importance of organizational involvement and commitment in the successful application and translation of decision-making aids and other frameworks to guide practice.
We gathered input from a purposive sample of occupational therapists in Australia and Singapore who collectively work with a wide range of caseloads across acute, rehab, and community practice settings in various organizations. These data add to our previous work involving consultation about the HIPM with experienced therapists working in neurorehabilitation in Australia (Citation12). Therapists in the current study were diverse in terms of their years of experience working in neurorehabilitation, and their familiarity and experience of using the HIPM.
The cross-cultural element of gathering data from therapists from two different countries may have been confounded by the fact that participants in Australia were predominantly working in the community, while participants in Singapore were mostly working in hospitals. This was partly due to the differences in the two countries’ overall distribution of occupational therapists’ principal work setting: only 18.6% of Australian therapists worked in hospitals (Citation35), compared to 48.6% of Singaporean therapists working in public hospitals alone (Citation36). Although the modified nominal group technique was used to gather individual perspectives which were prioritized by participants to guide group discussions, group sizes were large at times, which may have limited in-depth perspectives from each participant.
Only therapists working in Australia and Singapore participated in this study. Since the HIPM has also been introduced via CPD workshops in other countries such as Canada, United States of America, and United Kingdom, further validation of its cross-cultural clinical utility involving participants from other countries would be beneficial.
All participants in the study were occupational therapists, despite physiotherapists and rehabilitation physicians also having an established role in the UL neurorehabilitation process. Although recruitment was not targeted solely toward occupational therapists, they formed the significant majority of clinicians who had attended workshops on the HIPM. This could be because the HIPM was developed by occupational therapists and aligns well with occupational therapy models and frameworks of holistically considering clients’ personal and contextual factors, and activity-based goals. In view of this study’s findings about the importance of multidisciplinary and transorganizational collaboration in the successful application of the HIPM in practice, future clinical utility studies should actively recruit other members of the multidisciplinary team in order to obtain more diverse perspectives.
In view of the deep complexity of decision-making in UL neurorehabilitation, future research could consider using individual interviews to gather richer and more in-depth data about therapists’ experiences and clinical reasoning processes when applying the HIPM in practice. This would further inform how therapists can be best supported to make more specific and tailored decisions in UL neurorehabilitation.
Lastly, to promote knowledge translation of applying the HIPM in practice, future research should demonstrate how to apply the HIPM to individualize UL neurorehabilitation. Client outcomes from using the HIPM to deliver UL interventions should also be investigated. Other clinically useful decision-making aids for UL neurorehabilitation exist (Citation12), and should also be validated for their clinical utility and client outcomes.
Conclusion
The HIPM was perceived across cultures as a clinically useful decision-making aid that guides a systematic approach to UL neurorehabilitation. Therapists perceived that the HIPM provided structure for clinical reasoning when making assessment and intervention decisions, informed goal-setting, and was a useful tool in facilitating communication with clients and multidisciplinary team members. However, systemic and organizational supports and barriers such as the availability of time and resources, organizational expertise and willingness to change, as well as teamwork and collaboration across disciplines and organizations impacted the use of the HIPM. At the individual level, therapists’ confidence, knowledge, skills, and openness to engage in behavioral change also influenced their application of the HIPM. These findings highlight the complexities of applying decision-making aids in practice. To optimize the HIPM’s clinical utility, organizations must encourage multidisciplinary and transorganizational collaboration, and support therapists to have the time, resources, and expertise required to carry out the HIPM’s assessments and interventions. Suggestions to improve therapists’ skills and confidence in using the HIPM included refresher training, training therapists in teams, ongoing mentorship and case study discussions, the provision of more supplementary resources, introducing the HIPM within occupational therapy university programs, as well as targeted training and formats of the HIPM for therapists with different levels of UL neurorehabilitation expertise.
Supplemental Material
Download MS Word (1.3 MB)Acknowledgments
This study was completed as part of the first author’s PhD candidature, which is supported by a UQ Graduate School Scholarship and the Goldburg Family Foundation Medical Research Scholarship.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Supplemental data
Supplemental data for this article can be accessed online at https://doi.org/10.1080/02699052.2023.2205661
Additional information
Funding
References
- Teasell R, Cotoi A, Chow J, Wiener J, Iliescu A, Hussein N, Foley N, Salter K. Evidence-based review of stroke rehabilitation. 18th ed. London (ON): Canadian Partnership for Stroke Recovery; 2018.
- Katz RT, Rymer WZ. Spastic hypertonia: mechanisms and measurement. Arch Phys Med Rehabil. 1989;70(2):144–55.
- Hatem SM, Saussez G, Della Faille M, Prist V, Zhang X, Dispa D, Bleyenheuft Y. Rehabilitation of motor function after stroke: a multiple systematic review focused on techniques to stimulate upper extremity recovery. Front Hum Neurosci. 2016;10:442. doi:10.3389/fnhum.2016.00442.
- Copley J, Kuipers K. Neurorehabilitation of the upper limb across the lifespan: managing hypertonicity for optimal function. Chichester (UK): John Wiley & Sons; 2014.
- Stroke Foundation. Clinical guidelines for stroke management [Internet]. Melbourne, Australia: Stroke Foundation; 2021 Mar 17 [accessed 2021 Nov 9]. https://informme.org.au/en/Guidelines/Clinical-Guidelines-for-Stroke-Management
- Hayward KS, Jolliffe L, Churilov L, Herrmann A, Cloud GC, Lannin NA. In search of Kipling’s six honest serving men in upper limb rehabilitation: within participant case-crossover experiment nested within a web-based questionnaire. Disabil Rehabil. 2020;44(10):1–9. doi:10.1080/09638288.2020.1815873.
- Hoffmann T, Bennett S, Del Mar C. Evidence-based practice across the health professions. 3rd ed. Chatswood, N.S.W: Elsevier; 2017.
- Schell BAB, Schell JW. Clinical and Professional Reasoning in Occupational Therapy. 2nd ed. Philadelphia, PA: Wolters Kluwer Health; 2018.
- Higgs J, Jones M. Clinical decision making and multiple problem spaces. In: Higgs J, Jones M Christensen N, editors. Clinical reasoning in the health professions. 3rd ed. New York, NY: Elsevier/Butterworth Heinemann; 2008. pp. 3–18.
- McDonnell MN, Hillier SL, Esterman AJ. Standardizing the approach to evidence-based upper limb rehabilitation after stroke. Top Stroke Rehabil. 2013;20(5):432–40. doi:10.1310/tsr2005-432.
- Kuipers K, McKenna K. Upper limb rehabilitation following brain injury: complex, multifaceted and challenging. Br J Occup Ther. 2009;72(1):20–28. doi:10.1177/030802260907200105.
- Tan A, Copley J, Fleming J. Decision-making aids for upper limb interventions in neurological rehabilitation: a scoping review. Disabil Rehabil. 2022;44(18):5291–309. doi:10.1080/09638288.2021.1924881.
- Copley J, Kuipers K. Management of upper limb hypertonicity. San Antonio, Tex: Therapy Skill Builders; 1999.
- Stander J, Grimmer K, Brink Y. Tailored training for physiotherapists on the use of clinical practice guidelines: a mixed methods study. Physiother Res Int. 2021;26(1):e2174. doi:10.1002/pri.1883.
- Kuipers K, Grice JW. The structure of novice and expert occupational therapists’ clinical reasoning before and after exposure to a domain-specific protocol. Aust Occup Ther J. 2009;56(6):418–27. doi:10.1111/j.1440-1630.2009.00793.x.
- Smart A. A multi-dimensional model of clinical utility. Int J Qual Health Care. 2006;18(5):377–82. doi:10.1093/intqhc/mzl034.
- Thorne SE. Interpretive description: qualitative research for applied practice. 2nd ed. New York, NY: Routledge; 2016.
- Thompson Burdine J, Thorne S, Sandhu G. Interpretive description: a flexible qualitative methodology for medical education research. Med Educ. 2021;55(3):336–43. doi:10.1111/medu.14380.
- Van de Ven AH, Delbecq AL. The nominal group as a research instrument for exploratory health studies. Am J Public Health. 1972;62(3):337–42. doi:10.2105/ajph.62.3.337.
- Patton MQ. Qualitative research & evaluation methods: integrating theory and practice. 4th ed. Thousand Oaks, California: SAGE Publications, Inc.; 2015.
- Harrison MB, Graham ID. Knowledge translation in nursing and healthcare: a roadmap to evidence-informed practice. Hoboken, NJ: John Wiley & Sons; 2021.
- Körner M, Bütof S, Müller C, Zimmermann L, Becker S, Bengel J. Interprofessional teamwork and team interventions in chronic care: a systematic review. J Interprof Care. 2016;30(1):15–28. doi:10.3109/13561820.2015.1051616.
- Rosen MA, DiazGranados D, Dietz AS, Benishek LE, Thompson D, Pronovost PJ, Weaver SJ. Teamwork in healthcare: key discoveries enabling safer, high-quality care. Am Psychol. 2018;73(4):433–50. doi:10.1037/amp0000298.
- Colclough S, Copley J, Turpin M, Justins E, De Monte R. Occupational therapists’ perceptions of requirements for competent upper limb hypertonicity practice. Disabil Rehab. 2015;37(16):1416–23. doi:10.3109/09638288.2014.972585.
- Copley J, Kuipers K, Fleming J, Rassafiani M, Wood RL. Individualised resting hand splints for adults with acquired brain injury: a randomized, single blinded, single case design. NeuroRehabilitation. 2013;32(4):885–98. doi:10.3233/NRE-130913.
- Kuipers K, Grice JW. Clinical reasoning in neurology: use of the repertory grid technique to investigate the reasoning of an experienced occupational therapist. Aust Occup Ther J. 2009;56(4):275–84. doi:10.1111/j.1440-1630.2008.00737.x.
- Otterman NM, Maas M, Schiemanck SK, Vab der Wees P, Kwakkel G. Development and validity of an innovative test to assess guideline-consistent clinical reasoning by physical therapists in stroke rehabilitation. J Rehabil Med. 2019;51(6):418–25. doi:10.2340/16501977-2562.
- Kibicho J, Pinkerton SD, Owczarzak J. Community-based pharmacists’ needs for HIV-related training and experience. J Pharm Pract. 2013;27(4):369–78. doi:10.1177/0897190013513301.
- Davis DA, McMahon GT. Translating evidence into practice: lessons for CPD. Med Teach. 2018;40(9):892–95. doi:10.1080/0142159X.2018.1481285.
- Forsetlund L, O’Brien MA, Forsén L, Mwai L, Reinar LM, Okwen MP, Horsley T, Rose CJ. Continuing education meetings and workshops: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2021;2021(9). doi:10.1002/14651858.CD003030.pub3.
- Ramani S, McMahon GT, Armstrong EG. Continuing professional development to foster behaviour change: from principles to practice in health professions education. Med Teach. 2019;41(9):1045–52. doi:10.1080/0142159X.2019.1615608.
- Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: an updated synthesis of systematic reviews. J Contin Educ Health Prof. 2015;35(2):131–38. doi:10.1002/chp.21290.
- Lockyer JM, Fidler H, Ward R, Basson RJ, Elliott S, Toews J. Commitment to change statements: a way of understanding how participants use information and skills taught in an educational session. J Contin Educ Health Prof. 2001;21(2):82–89. doi:10.1002/chp.1340210204.
- Steiner B, Saalfeld B, Elgert L, Haux R, Wolf K-H. OnTARi: an ontology for factors influencing therapy adherence to rehabilitation. BMC Med Inform Decis Mak. 2021;21(1):153. doi:10.1186/s12911-021-01512-y.
- Australian Government Department of Health. Factsheet, occupational therapists, 2019 [Internet]. Canberra: Department of Health; 2020 [cited 2023 Apr 23]. 10p. Available from https://hwd.health.gov.au/resources/publications/factsheet-alld-occupational-therapists-2019.pdf
- Allied Health Professions Council. Annual Report 2022 [Internet]. Singapore: Allied Health Professions Council; 2022 [cited 2023 Apr 23]. 43p. Available from https://www.healthprofessionals.gov.sg/docs/librariesprovider5/announcements/2022_ahpc-annual-report_v7-(final).pdf