Occupational Therapists’ perspectives of implementing a new rehabilitation intervention for visual field loss due to stroke

Patient and Public Involvement

Patient and public involvement is at the heart of the HABIT program. The patients were heavily involved in the development and design of this study. Wider stakeholder engagement in the form of healthcare professionals from a range of specialties as well as patient representatives collaborated with the research team to advise on the data collection methodology and the content of the interview schedule.

Context: Setting

This qualitative research was part of a larger feasibility study. This study was reviewed by the Wales Research Ethics Committee 4 Wrexham Research Ethics Committee (REC: 20/WA/0093) and by the Health Research Authority and Health and Care Research Wales (IRAS: 270718). The study was conducted from October 2019 to November 2021 and included the height of the COVID-19 pandemic. There were five sites that delivered the new HABIT intervention: four hospitals and one community stroke care setting.

Context: Intervention

HABIT is designed to enable standardized, comprehensive, best practice OT care for stroke survivors with visual field loss. It incorporates the principles and practical methods of both visual search and scanning training for visual field loss, as described above, and OT care, using activity-based training tailored to the impairments and valued activities of the individual, with increasing complexity and intensity. It also includes the provision of information, which is seen as a key first step in achieving effective compensatory behaviours.

Key stages in delivering HABIT to a stroke survivor with field loss are:

The intervention materials consisted of tools to train therapists on how to deliver HABIT. These cover the rationale, key components, and methods to conduct HABIT processes and activities with stroke survivors in a range of settings. Training materials are a therapy manual and online training via a recorded video and live problem solving. Second, tools help support the delivery of HABIT to individual patients, their families, and caregivers. These include written materials such as information sheets, practice activities leaflet, and vision screening summary, plus a dedicated website including videos on the experience and impact of visual field loss and examples of successful rehabilitation.

Participants

All OTs who delivered HABIT during the feasibility study were approached to be interviewed, and all agreed. Therefore, all recruiting sites were represented in the data collection, and all participants had recent experience in delivering the HABIT intervention. Informed consent was obtained in writing during site initiation visits.

Data collection

Data were collected through semi-structured online interviews, lasting up to one hour, conducted using Zoom (Zoom Video Communications Inc.). Interviews were undertaken by SH, a Health Psychologist and Research Fellow. The interviews were audio-recorded and transcribed verbatim.

The interview schedule covered participants’ thoughts about the barriers and facilitators of HABIT implementation in healthcare practice (Interview schedule is available at https://osf.io/3cwmf/). The interviews covered the full scope of the intervention, including training, intervention delivery, supporting materials, and the website.

Analysis

The analysis was performed by two authors (CH and SH). CH is an Optometrist and Research Fellow. Both CH and SH had training and experience in undertaking and reporting qualitative research. Both were female with doctoral qualifications (PhDs).

The template analysis methodology was applied to the interview transcripts. This method supports a hybrid approach of both deductive (a priori) and inductive qualitative analysis; in this case, the a priori implementation framework (COM-B) remains open to the possibility that the framework was not completely implementable within the study context^30,31.

Following the transcription of the interviews, NVivo 12³² was used with the King & Brooks²⁸ template process to facilitate qualitative content analysis. Integrating initial thoughts, the researchers looked for diversity and similarity in the transcripts, started to make meaning from the dataset, and applied labels to specific segments of the transcript/data. Subsequently, the a priori framework of COM-B was applied³³.

The COM-B framework breaks the drivers of behaviour (B) into three categories: capability (C), opportunity (O), and motivation (M). Capability refers to an individual’s ability to participate in an activity and consists of both physical and psychological components. Opportunity relates to external factors that make a target behaviour possible and can be both social and physical. Motivation concerns internal processes that influence decision making and behaviours. Barriers and facilitators of implementation were drawn into themes under these categories; participants' individual comments were reported where they illuminated their particular experiences.

Capability

Overall, HABIT was perceived to be similar to what the OT participants were already doing. For some participants, this acted as a validation of their work, reassuring them that what they delivered was backed by the research:

Other OTs reported disappointment regarding the limited development of their underlying level of knowledge and practical skills used in delivering care:

HABIT was perceived as most valuable for those less familiar with treating visual field loss, such as OTs new to stroke care and members of other professions in the stroke team, with its main function as a training tool.

A number of OTs reported benefits to their practice relating to how HABIT provided both new ideas and approaches for, and a structure for, the management of visual field loss. This increased the consistency and thoroughness with which vision was addressed and provided a framework for vision-related goal setting. HABIT also increased the attention and time paid to vision; the HABIT paperwork supported this structured approach.

Of particular value was the sheet where the OTs could record and display the nature of a patient’s visual loss. OTs reported that this improved their ability to explain an individual’s visual field loss to them and their families.

The online tool and examples were noted to increase capability in some stroke survivors, enabling self-practice and self-management of their visual field loss, with online case studies acting as a form of peer support.

Opportunity

The opportunity to use HABIT was limited by factors related to HABIT resources and the environment of the intervention delivery. Resource concerns centered on features of the HABIT tool itself: A key barrier was the requirement to complete a range of paperwork, covering provision of information, goal setting and achievement, and records of visits, which were considered excessive.

In the acute hospital setting, the paperwork related to goal setting was difficult to complete because there was insufficient time for the patient and therapist to identify important goals:

The inclusion of online components was a concern because devices such as laptops or tablets were not always available in the ward.

OTs working in acute settings felt that the intervention was designed primarily for use in a community setting, and as the examples were primarily for a home setting, it was difficult to implement. To do so required the addition of new activities that could be conducted in the ward and further consideration and discussion by the team to tailor the given examples to an inpatient setting.

Motivation

Motivation was key to determining the extent to which HABIT was implemented. Two elements were highlighted: goal priority and beliefs about patients' capabilities and opportunities.

Goal priority. The priority given to vision by the OTs was critical to their motivation to use HABIT. It was evident that OTs’ prioritization of vision care included consideration of a range of individual, service, and participant-related factors. From the participants' responses, this prioritization related to addressing vision as a whole, and not just the use of HABIT to do so.

In the interviews, prioritization was described as an intersection between an opportunity factor (the amount of time available) and motivation (the relative importance given to addressing visual impairment compared to other elements of post-stroke care). This dynamic interaction was influenced by context and was most notable in an acute rather than a community setting. In an acute setting, the OTs clearly stated a lack of time to complete a broad range of tasks for each patient:

OTs prioritized the issues they considered to be most important: vision was often not considered important, nor was it a main concern for care. The most important aspects were discharge, assessment and management of mobility, and risk management. Consequently, HABIT is not used by everyone. The OTs stated that if they tried to address vision, it would take time away from these, higher priority, and clinical issues.

Clinicians stated that patient priorities should be considered. When patients themselves did not place importance on their vision, it was difficult to motivate them to engage in vision rehabilitation. Again, this was linked specifically to an acute setting, where patients were primarily focused on getting home and OT care that would enable this.

Additionally, as they (the patient) were in unfamiliar surroundings, OTs felt that patients were not fully aware that they had lost half of their vision. Patients had not yet experienced the impact this could have on their daily lives, and so did not stress this element of care.

Hospital-based clinicians stated that ‘community is the best place’ for HABIT implementation, due to the factors of time, ability to goal set and practice in relevant tasks and patient motivation noted above.

Beliefs about patients' capabilities and opportunities. The OTs’ motivation was linked to their beliefs about the capability of a patient to engage with and benefit from the intervention.

This is related in part to the interaction between the patient and the tools. Visual, language, and cognitive impairments could limit the patients' ability to benefit. In particular, supporting materials, such as written information documents and online tools, are very visual in nature, with both text and graphics. Patients had visual impairment and struggled to engage with these materials, which limited their benefit from the intervention. However, online videos were considered useful because the narrative could be listened to by the patients.

The perceived lack of familiarity with, or access to, computers was also a barrier.

The OTs frequently mentioned the relevance of tools within their care settings. Some participants felt that the examples and activities provided were appropriate and pertinent. Where this was the case and when a patient was considered able to engage fully, this was highly motivating.

Greater accessibility of HABIT materials is vital for its uptake and use

Participants reported that the use of HABIT was limited by difficulties in accessing online materials and the inability of patients to use written HABIT documents.

OTs found it difficult to access the electronic devices required to use online resources. One tablet was provided per site; however, this was insufficient and meant that devices could not be left with patients to explore the HABIT website themselves. In addition, OTs’ beliefs about older patients’ poorer ability to use digital technology have reduced its introduction. It is not clear whether these beliefs aligned with patients’ actual ability to use computers or instead reflected participants’ preconceptions about more elderly patients³⁴.

Accessibility of written content, which was a core element of the intervention, was limited to patients with visual, cognitive, and/or language impairments. Given that the target population was those with visual field loss, this was a central barrier to address. The development process involved the multidisciplinary HABIT team (including two people with visual loss due to stroke) and a focus group of people with lived experience of visual loss after stroke, but materials proved challenging. In the future, HABIT must find new ways to enable access to written and visual information. These may include simplification of presentation and language, greater use of audio, using a more participatory approach to the design process, and greater input from low-vision rehabilitation specialists³⁵.

Visual impairment caused by stroke was not seen as important

The participants stated that they felt that visual field loss was a minor problem for stroke survivors. This view conflicts with the current evidence on the broad and long-lasting impact of visual loss due to stroke¹⁴ and must be challenged. However, the reason for this is unclear. The impact on quality of life is not always fully evident until months after stroke¹⁵ and therefore may not have been visible to those working in acute services. This may reflect a lack of vision-specific training for OTs, with stroke survivors in another study reporting a “lack of knowledge and limited interest” from healthcare professionals³⁶. Interestingly, a study assessing the implementation of a vision assessment program in Norway found that training on the impact of visual impairment caused by stroke was a key factor driving clinicians’ motivation to implement the intervention, as it made them aware of the importance of addressing vision as soon as possible³⁷. Further research is needed into OTs’ awareness and understanding of visual field loss and its impact, and how any barriers arising could best be addressed via amendments to HABIT, or other educational approaches.

OTs also stated that HABIT may be more appropriate for the community setting; in other words, addressing visual field loss was more important in the post-acute stage. OTs felt that stroke survivors lacked awareness of field loss while in the unfamiliar ward setting ward, and thus did not see the value of vision rehabilitation. They also stated that goal setting and rehabilitation, which should be founded on everyday activities, should largely wait until patients are discharged home. At present, there is insufficient evidence to determine the optimal timing for vision rehabilitation¹⁹, and further work, including gathering stroke survivors’ opinions, is required.

HABIT needs to be delivered in a more efficient way in an acute ward, to respond to time pressures

OTs noted prioritizing activities that enabled a fast and safe discharge, which often focused on motor skills; time spent delivering HABIT was seen as time diverted away from key tasks. The associated paperwork was also considered to be too long and onerous. These points and wider study findings suggest potential refinements to make HABIT more suitable for the acute context. First, HABIT should include exercises that combine visual search training with activities addressing OTs’ priorities, such as balance and mobility, so that each is addressed in a time-efficient manner. HABIT should include clear ward-based examples so that OTs can practically operationalize this training. Second, HABIT should enable greater flexibility regarding which elements should be delivered in the acute stage. Participants valued documents that facilitated information provision to patients; they also identified that patients would not be sufficiently aware of their visual loss and its impact. Together, these findings suggest that increasing the understanding of visual field loss and its impact on activities should be an early focus of HABIT. Third, HABIT paperwork should be edited to reduce the time required to complete it. We recognize that this study took place when UK hospital time pressures were particularly severe owing to COVID-19. Although this critical time point has passed, pressures on NHS services remain severe, and these findings are likely to reflect ongoing concerns³⁸.

This study is the first to explore clinicians’ perspectives on implementing any vision rehabilitation intervention for any post-stroke visual impairment in a UK care setting. A strength of this study is the use of first-hand accounts, which enabled the gathering and exploration of a range of opinions. Interviews promoted flexibility and participant engagement, and fostered reflexivity while appreciating the complexity of human opinions. Interviews were conducted by a researcher who was not previously known to the participants, acting to minimize bias towards more favourable socially desirable responses³⁹.

Ethics approval and consent to participate

This work is a sub-study of an ethically approved program assessed by Wales Research Ethics Committee 4 Wrexham Research Ethics Committee (REC: 20/WA/0093) and by the Health Research Authority and Health and Care Research Wales (IRAS: 270718). Informed consent was obtained in writing during site initiation visits.