Date Presented 04/06/19
This quantitative, cross-sectional survey design study conducted with 409 OTs investigated the influence of practice and personal context factors on the choices that OTs make when addressing upper-extremity contractures. In interventions that had a high likelihood of being used, specifically static splinting, stretching, and positioning, there were no practice context barriers found, yet it was with these interventions that there was little belief in their effectiveness.
Primary Author and Speaker: Heather Thomas
PURPOSE: The purpose of this study was to investigate the influence of practice and personal context factors on the intervention choices that occupational therapists make in addressing upper extremity contractures.
DESIGN: This study was a quantitative, cross-sectional survey design, conducted with a sample of 409 occupational therapists who address upper extremity contractures.
METHOD: A questionnaire was developed which included all of the variables of study, using the work of previous researchers who aimed at uncovering factors behind clinical reasoning of clinicians. The population of study was occupational therapists who address upper extremity contractures. This study was a cross-sectional survey design. The survey was made available through an online service, with a link sent to potential participants, using snowballing technique to reach practitioners across the United States. IBM SPSS Statistics for Windows version 19 was utilized to analyze the data. Logistic multiple regression was used to investigate the influence of each categorical independent variable on the dichotomous dependent variable of likely/unlikely to use each intervention option.
RESULTS: Respondents felt most skilled in using positioning, stretching/ passive range of motion, and static splinting and felt least skilled in using serial casting and electrical stimulation to address contractures. Hypotheses regarding the positive relationship between clinician belief and likelihood of use were rejected with, stretching/PROM, as logistic regression models including all variables as possible covariates found there was not a positive association between belief and likelihood. Logistic regression analyses found that the odds of likelihood of use of some of the intervention options are influenced by skill level, lack of belief in effectiveness, lack of materials and high caseload (p<.05). The lack of materials and equipment was identified as a barrier in home health, skilled nursing facilities and long term care facilities; high caseload was identified as a barrier in skilled nursing facilities and acute hospitals. The leading overall practice context barrier identified was the lack of insurance coverage however in logistic regression analyses there was no significant relationship to the odds of likelihood of use of any of the intervention methods. The overall effect sizes of the logistic regression models were small ranging from .13-.36. A post-hoc power analysis determined that this study had an average effect size of .20, resulting in power of .88 (n=409, a=05).
CONCLUSION: It was found that with the interventions which had a high likelihood of being used, specifically static splinting, stretching/PROM, and positioning, there were no practice context barriers found, yet it was with these interventions that there was little belief in the effectiveness of these interventions. These interventions also had the highest ranked skill level. In those interventions in which there was low likelihood of use, electrical stimulation and serial casting, one of the leading barriers to likelihood of use was lack of skill, showing that there is a need for education. The lack of materials and high caseload were found to having an impact on the use of some intervention options, which is an indicator of the condition of our current health care system and the impact it has on clinician autonomy. This study sheds light on those aspects of the personal and physical contexts which limit best-practice and autonomy in occupational therapy when addressing contractures. By identifying those barriers, the profession can begin to address the gap in knowledge, gain access to equipment and materials, and why interventions are being used despite lack of belief in effectiveness.
References
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