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BACKGROUND/RATIONALE:
SCI QUERI's mission is to identify and address knowledge gaps and promote research to improve the medical care, health-related quality of life and community integration for persons with SCI, and one of its priorities is to address pain and function in SCI. Upper limb pain is highly prevalent in persons with spinal cord injury (SCI) and the functional consequences can be devastating. Most persons with SCI have increased biomechanical challenges and use their upper limbs to compensate for loss of lower limb function. Their upper limbs are used to propel a wheelchair, lift and transfer their body, and perform other weight-bearing tasks. Since life expectancy has increased for persons with SCI, upper limb weight-bearing is often performed for many decades; thus preserving upper limb function is critical to sustain independence into later life.
OBJECTIVE(S):
The Consortium for Spinal Cord Medicine recently published guidelines entitled, “Preservation of Upper Limb Function Following SCI: A Clinical Practice Guideline for Health Care Professionals” (2005)1. The purpose of this rapid response study is to identify performance gaps, and barriers and facilitators to implementing these guideline recommendations in VA SCI Centers. Using a qualitative research design, this 6 month project will address two questions, from three perspectives: health care providers, veterans, and key informants: (1) Assess key stakeholder perceptions regarding gaps in performance associated with routine assessment, prevention, and treatment of upper limb pain and loss of function for persons with SCI. (2) Assess key stakeholder perceptions regarding barriers and facilitators to routine assessment, prevention, and treatment of upper limb pain and function for persons with SCI.
METHODS:
Study Design: Focus group methods will be used to more fully understand gaps in performance for providing quality care, and the underlying individual, interpersonal and organizational reason for these gaps. Additionally, gaps analysis can be used to identify factors contributing to performance gaps and reasons for failures in implementing guideline recommendations. Knowledge of these contributing factors and reasons for failure can be used to identify potentially successful strategies for closing gaps and removing barriers to innovation. To increase the value of the focus group experience, we will ask providers to complete a short web-based survey in advance. The survey will ask respondents to rate their level of agreement with each of the recommendations, and to indicate which guidelines are either already implemented at their facility, ready for implementation, or require additional efforts before implementation would be possible. The survey results will be used to fine tune focus group questions. Sample: The sample will include a purposeful sample of 21 SCI providers (3 groups of 6-8 participants) and 21 veterans with SCI (three groups of 6-8 participants); both groups will be recruited equally from the Tampa, Hines, and Seattle VAMCs. Providers will include (physicians, nurses, nurse practitioners, and physician assistants), rehabilitation staff (physical therapists, occupational therapists, and kinesiotherapists) and staff from other relevant services (psychology, nursing, etc) who provide direct patient care and have dealt with issues of upper limb pain and injury. SCI veterans will include inpatients and outpatients with a diagnosis of SCI for at least 1 year and use a manual wheelchair as the primary means for mobility. In addition, we will interview by telephone, key informants identified during the focus groups. Focus Group Procedures. Six focus groups of 6-8 participants each will be held. The trained focus group facilitator will conduct the focus group using telephone conferencing at the Hines and Seattle VA, and in person at Tampa. The facilitator will briefly deliver an overview of the project, explain the study's confidentiality rules, and obtain participants' informed consents-including permission to audio tape the discussion to assist with analysis. A local site assistant will coordinate logistics of the groups on site, and make handwritten notes to capture, particularly, nonverbal communication and elements of group dynamics that are not evident in audio tape recordings. Data Analysis: Survey data will be analyzed using frequencies and means. Hand-written notes from focus groups and audio tape transcriptions will be analyzed using content analysis by the facilitator, investigators and the Tampa VA. After each focus group, the facilitator and local site assistant will hold a telephone debriefing session to compare and contrast perceptions of key findings. Points of agreement and discrepancies will be discussed and decisions will be made jointly to determine final categories. During analysis, sections of text will be marked to identify particularly salient or well expressed quotes illustrative of major codes.
FINDINGS/RESULTS:
No results at this time.
IMPACT:
ANTICIPATED IMPACT: A large proportion of veterans with SCI&D report debilitating upper limb pain. Although guideline recommendations have been disseminated regarding the preservation of upper limb functioning, there is anecdotal information that many gaps exist in applying these recommendations to clinical practice. Before the guidelines can be implemented we need to identify the extent of the gaps, barriers to implementation, and facilitators to overcome these barriers. We intend to design a multi-site study within VA SCI Centers to enhance provider adherence to the guidelines, improve patient functioning, decrease upper limb pain, and improve quality of life. This pilot work will lay the foundation to (1) select which recommendations for the focus of our next study, and (2) design targeted interventions likely to be successful and well accepted.
PUBLICATIONS:
None at this time.
DRA:
Acute and Traumatic Injury
DRE:
Rehabilitation, Treatment
Keywords:
Spinal cord injury
MeSH Terms:
none
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