Gustavson Allison M, LeDoux Cherie V, Stutzbach Julie A, Miller Matthew J, Seidler Katie J, Stevens-Lapsley Jennifer E
Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora.
Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota.
J Geriatr Phys Ther. 2021;44(2):108-118. doi: 10.1519/JPT.0000000000000288.
Postacute care reform is driving physical and occupational therapists in skilled nursing facilities (SNFs) to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. This study explored what determinants impacted change in care delivery at 2 SNFs that implemented a high-intensity resistance training intervention.
We used a mixed-methods, sequential explanatory design to explain quantitative findings using qualitative methods with a multiple-case study approach. Quantitative data were collected on therapists' attitudes toward evidence-based practice and aspects of intervention implementation. We conducted focus groups with therapists (N = 15) at 2 SNFs, classified as either high- (SNF-H) or low-performing (SNF-L) based on implementation fidelity and sustainability.
Determinants of SNF rehabilitation practice change included the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions. A patient-centered system, positive team dynamics, and ability to overcome preconceived notions fostered practice change at SNF-H. While self-efficacy and perception of effectiveness positively impacted change in practice at both SNFs, these determinants were not enough to overcome challenges at SNF-L. To adapt to changes and sustain rehabilitation value, further research must identify the combination of determinants that promote application of evidence-based practice.
This study is the first step in understanding what drives change in SNF rehabilitation practice. As SNF rehabilitation continues to face changes in health care delivery and reimbursement, therapists will need to adapt, by changing practice patterns and adopting evidence-based approaches, to demonstrate value in postacute care.
急性后期护理改革促使熟练护理机构（SNFs）中的物理治疗师和职业治疗师改变护理方式，以便在更短时间内取得更好的效果。然而，在理解实践变革的决定因素方面存在差距，这限制了将证据转化为实践。本研究探讨了哪些决定因素影响了两家实施高强度阻力训练干预的熟练护理机构的护理提供方式的变化。
我们采用混合方法、序列解释性设计，通过多案例研究方法使用定性方法来解释定量研究结果。收集了治疗师对循证实践的态度以及干预实施方面的定量数据。我们在两家熟练护理机构与治疗师（N = 15）进行了焦点小组讨论，根据实施保真度和可持续性将其分为高绩效（SNF-H）或低绩效（SNF-L）两类。
熟练护理机构康复实践变革的决定因素包括组织系统、团队动态、患者和治疗师的自我效能感、对干预效果的认知以及克服先入之见的能力。以患者为中心的系统、积极的团队动态以及克服先入之见的能力促进了高绩效熟练护理机构的实践变革。虽然自我效能感和对效果的认知对两家熟练护理机构的实践变革都有积极影响，但这些决定因素不足以克服低绩效熟练护理机构面临的挑战。为了适应变化并维持康复价值，进一步的研究必须确定促进循证实践应用的决定因素组合。
本研究是理解熟练护理机构康复实践变革驱动因素的第一步。随着熟练护理机构康复继续面临医疗保健提供和报销方面的变化，治疗师将需要通过改变实践模式和采用循证方法来适应，以在急性后期护理中展现价值。
