Implementing structured vision assessment in stroke care services: The KROSS knowledge translation project
Doctoral thesis
Published version
Permanent lenke
https://hdl.handle.net/11250/2996240Utgivelsesdato
2022Metadata
Vis full innførselSamlinger
Sammendrag
Background
Stroke is a leading cause of death and disability in Norway and internationally. Many
functions can be affected by stroke and vision is one of them. Visual impairments (VIs)
affect 60% of all stroke survivors, and includes reduced visual acuity, eye movement
disorders, visual field defects and perceptual deficits. Post-stroke VIs can lead to a
number of negative consequences. It reduces the effect of general rehabilitation, cause
immobilisation and reduced participation in activities, and reduced quality of life. Vision
rehabilitation and individually adapted information for the stroke survivor and their
caregivers can reduce the negative effects of post-stroke VIs. Post-stroke VIs are often
overlooked by the stroke survivors and healthcare professionals. To identify post-stroke
VIs, the visual function needs to be assessed. Even so, visual assessment is not an
integral part stroke care. This represents a gap between knowledge about
post-stroke Vis and the current practise in Norway.
Aim
The main aim of this project was to improve stroke care by implementing structured
vision assessment in Kongsberg municipality using an adapted version of the KROSS (a
Norwegian acronym standing for Competence and Rehabilitation of Sight after Stroke)
vision assessment tool. Another aim was to increase the competence and awareness
post-stroke VIs among health care personnel. The aims of the three sub-studies are
based on different parts of the implementation process. Sub-study 1 explores
stroke survivors’ experiences of vision care in within stroke health services.
The second study assess barriers and facilitators to the implementation of a structured
vision assessment in the municipal health care service. In the third study,
the implementation outcomes are evaluated.
Methods
We used the Knowledge To Action (KTA) model to plan and organise the implementation
project. The KTA model describe the different components in the implementationprocess,
and consists of a ‘Knowledge Creation’ part and an ‘Action Cycle’ part. We applied a
collaborative approach to the implementation and the three sub-studies and
included relevant stakeholders in all parts of the implementation. All three sub-studies
are qualitative studies. Sub-study 1 is a qualitative interview study with in-depth
interviews of 10 stroke survivors with post-stroke VIs. Study 1 and 2 were analysed using
inductive content analysis. Sub-study 2 include individual interviews with 11 health
professionals and managers. In addition, we included data from two workshop
discussions with a total of 26 participants. The results from sub-study 1 and 2 were used
in planning and organising the implementation. Sub-study 3 consisted of four focus group
interviews. The study had a deductive-inductive approach, and we used a framework for
implementation outcomes.
Results
‘Invisible’ vision problems – was the main theme in sub-study 1. The theme represents
how the participants experienced post-stroke VIs as an unknown and difficult symptom
of stroke. The participants experienced a lack of attention to, and follow-up of their VIs
in the health services. VIs was highlighted as a main hinder returning to living the life they
had before the stroke. In sub-study 2, individual and contextual barriers and facilitators
were identified. The individual barriers were related to the participants' experiences of
having low competence of visual function and assessment. They considered themselves
as generalists, not stroke experts. Some participants were reluctant due to previous
experiences with unsuccessful implementation projects. Individual facilitators were the
belief that including vision assessment would improve their services for stroke survivors.
If the tool was perceived as useful and evidence based, it would be easier to implement.
Contextual barriers were experiences of unclear responsibility for vision care, lack of
structured interdisciplinary collaboration and lack of formal stroke routines. Time
constraints and practical difficulties related to include the vision tool in the medical
records were other contextual barriers. Contextual facilitators were leader support and
acknowledgement, in addition to having a flexible work schedule. In sub-study 3, the
participants expressed that the structured visual assessment with the KROSS tool was
acceptable in their clinical practice. They were motivated to use the new routine
because they acknowledged that the visual function influenced other functions, such as
mobility and activities of daily living. Most of the participants reported having adopted
KROSS, except for the home care service which experienced that they saw few stroke
survivors in their service. They all reported increased attention and awareness to post-stroke VIs.
The KROSS assessment was considered to be most appropriate in the rehabilitation
services where they already perform many function assessments. Although vision
assessment was new to all participants, they felt they became more confident in
performing the assessment when they used the tool frequently. The good user manual
and supervision in their own practice, they experienced the vision assessment as
feasible. That the vision assessment was included in the existing routines and systems
was important to promote a sustainable implementation.
Conclusion
This knowledge translation project and the three sub-studies have generated new and
important insight about the implementation of structured vision assessment after stroke.
The three studies provided insight to the gap between knowledge and action from the
perspectives of the stroke survivors, but also from the health care personnel who
described that they lacked knowledge and skills about visual function and assessment.
Stroke survivors from several organizations participated throughout the project and
contributed with their experiences and acted as demo patients in the workshops. This
was emphasized by the health care personnel as especially motivating. We developed
many different strategies to implement the KROSS tool, especially important was the
workshops to promote knowledge and skills in assessing vision. In addition arrangements
made to supervise the participants practising the KROSS tool were also valuable. The
KROSS tool has been adopted in the rehabilitation unit and home rehabilitation in
Kongsberg municipality, a stroke unit and the rehabilitation hospital. Using the KTA model
to plan and complete the implementation was important for the outcome of the project,
because it provided an overview of important elements of the implementation process.
The collaborative approach was important for involving and create enthusiasm from
health care managers and practitioners in the implementation, promoting a sustainable
routine for vision assessment in the municipality