Poststroke outcome measure implementation fails to address NPT components

Implementation strategies for the Fugl-Meyer Assessment (FMA), a gold-standard poststroke upper limb outcome measure, fall short of addressing key components of the Normalisation Process Theory (NPT), particularly coherence and reflexive monitoring, according to a Singapore study.

“Commonly employed multifaceted implementation strategies, including education, may not sufficiently address key barriers to their consistent integration into routine practice,” the researchers said.

“These gaps hinder the consistent integration of standardized outcome measures into routine clinical care,” they added.

This qualitative multiple case study conducted in four public hospitals in Singapore was grounded in NPT. The research team conducted interviews with occupational therapists involved in the original FMA implementation and collected documents from the planning and initial stages of implementation.

Data analysis was also carried out, which included systematic deductive and thematic approaches, within- and cross-case analysis, and mapping implementation strategies to the NPT.

Eight participants were interviewed. Varying implementation activities were observed across hospitals based on the results of the interviews and document analysis. [Proc Singap Healthc 2025;doi:10.1177/20101058251318755]

All four hospitals used multifaceted strategies when introducing the FMA into clinical practice. Such strategies were as follows: educational meetings, distribution of educational materials, use of local opinion leaders, local consensus processes, and reminders.  

While these hospitals focused on education and training, one acute hospital performed audits and tailored interventions. Implementation was influenced by organizational contexts, specifically differences in care models and commitment to outcome measurement.

Although the strategies aligned with “cognitive participation” and “collective action” constructs of the NPT, strategies for “reflexive monitoring” and “coherence” were limited.

“[These] findings underscore the importance of a nuanced approach considering both implementation strategies and practice context,” the researchers said. “Key targets were identified to inform future tailored strategies for improving the consistency of using post-stroke upper limb outcome measures.”

Employing multifaceted implementation strategies aligned with the results of a scoping review, in which occupational therapists implementing evidence-based practice in stroke rehabilitation used a median of four implementation strategies. The most common strategy was education-related interventions. [Implement Sci 2021;16:105]

Active, passive strategies

The current study found the use of both active and passive strategies by all four hospitals, instead of relying on education alone, “encouraging.”

“Active strategies, such as interactive workshops, hands-on training, and individualised feedback, engage healthcare professionals,” the researchers said. [Med Teach 2007;29:38-42]

“In contrast, passive strategies, including the distribution of guidelines, informational material, and reminders, require less active engagement from clinicians but still disseminate crucial information,” they added. [Cochrane Database Syst Rev 2020;10:CD01257]

A previous systematic review found that education alone shows a limited capacity in changing the clinical practices of healthcare professionals. This finding indicated that both active and passive strategies may be more effective in achieving the desired practice change, according to the researchers. [Implement Sci 2012;7:70]

“Upper limb deficits are common after stroke, leading to daily activity limitations and potential caregiver dependence,” the researchers said.

“Consistent assessment of upper limb function is crucial for effective rehabilitation, but its inconsistent implementation across clinical settings necessitates tailored strategies for adherence to outcome measurement and optimal patient care,” they added.