This study exposed challenges to implementing an evidence-based LEAP for multidisciplinary post-amputation rehabilitation. Top ranked barriers included clinician confidence with specific interventions, lack of clinical LEA experience and clinical training; interdisciplinary coordination and communication; and knowledge of problems delaying hospital discharge. Top barriers reflected multidisciplinary limited self-rated knowledge, clinical experience and competence in specific rehabilitation interventions. Variations across disciplines and experience levels suggest implementing multidisciplinary evidence-based practices could be facilitated with interventions tailored for specific disciplines’ needs. Broad unfamiliarity with CPG evidence may be because the LEA population is relatively small. Since clinical experience, competence, confidence, and training were top barriers, one recommendation was to increase referrals, and thus LEA patients with whom to gain experience, using an automated multidisciplinary referral system with standard order set to improve referral consistency while facilitating interdisciplinary communication and coordination. Adopting a proximal strategy to potentially affect most mechanisms and distal outcomes may be a useful approach.
The capability, opportunity, and motivation domains of behavior change (COM-B) were used to organize recommended implementation interventions, recognizing that intended behavior change may arise from multiple factors and that proposed interventions may affect multiple behavioral change functions.28 Capability domain recommendations included education addressing knowledge and clinical skills gaps, experienced champions to provide clinical support, and an automated referral system with standard order set to enable multidisciplinary clinicians to provide their specialized care that rotating physicians in training may not be oriented to or unwittingly restrict through the absence of specific orders.18 An automated referral order set with corresponding electronic documentation system would also have an opportunity domain function by expanding opportunities for clinician LEA experience in this relatively small clinical population by reducing the number of LEA patients lost to oversight and removing restrictions multidisciplinary providers may perceive or self-impose based on cultural medical hierarchy.28 Motivation domain interventions have been less emphasized than capability and opportunity domain interventions in a Theoretical Domains Framework systematic review, though professional role and identity were frequently noted issues.29 The automated multidisciplinary LEAP referral system may empower disciplines not recognized for their contributions30 and motivate others disciplines via coercion of perceived requisite action and incentivism of potential cost savings associated with shorter lengths-of-stay.28 Together with interdisciplinary education and training and support from multidisciplinary champions, the LEAP automated referral system may foster a sense of team and group purpose while tapping into the propensity to mimic others.28 An automated referral system could be a single intervention that affects all three COM-B domains.
Identifying barriers and facilitators aids development of implementation strategies to facilitate the mechanisms required to implement new evidence-based practice protocols.31 This study was consistent with a systematic review identifying lack of clinician awareness of the relevant research as a top personal barrier for implementing research in practice.25 Insufficient knowledge leads to lower confidence29 thus education regarding CPG evidence and the problems of delayed rehabilitation appears foundational to implementing a multidisciplinary LEAP.32 Limited clinical experience and competence varied among disciplines, perhaps explaining why interdisciplinary communication and coordination were perceived barriers. Multidisciplinary variations helped identify champion clinicians to support educational training matching specific professional needs—such as postoperative limb dressings and early mobilization.32 Specific protocol elements for which multiple professions across experience levels lacked experience, competence, and confidence (semirigid/rigid dressings, temporary prostheses), could not be recommended. One commonly reported barrier, insufficient time to implement evidence-based practices,25,29 was not a major concern in this study, and clinician attitude was a facilitator, supported in self-rated confidence to adopt evidence-based limb dressings and early mobilization practices that exceeded self-rated clinical competence.
This study identified determinants leading to recommended strategies along a causal pathway that could plausibly lead to measurable implementation outcomes as recommended for effective change enactment.33 (Fig. 1) The identified barriers may not be isolated to one institution; others have attempted to initiate a postoperative LEAP at the institutional level.13,34 This study fits within a multi-level process (Fig. 2) in which system level efforts have already been enacted including post-amputation rehabilitation CPGs3,4 and the American Physical Therapy Association limb loss educational curricular guideline.19
At the organizational level (Fig. 2), the recommended automated multidisciplinary referral system would address institutional barriers such as insufficient patients with which to gain experience and multidisciplinary communication or coordination.13,34 This single recommendation could have multiple downstream effects. All professions could be automatically alerted to their roles to optimize multidisciplinary communication and coordination, all clinicians would have access to relevant outcome measures through the electronic documentation system, and more people with LEA would be referred, taking advantage of the fact that productivity was not a major barrier.
At the practitioner level (Fig. 2), results prompt recommendations addressing barriers and facilitators.31 Accessible educational programming and in-person training were recommended to address knowledge gaps regarding post-amputation problems delaying discharge and limited CPG awareness. Education interventions tailored for targeted professional groups can be supported by recruiting champions, capitalizing on clinician readiness to change. While long-term impact is the ultimate goal, implementing evidence-based practices can take years to enact as many factors influence health outcomes,2,33 thus improving patient level outcomes remains for future research. This study was constrained to identifying determinants to assist strategic planning for LEAP implementation.
Limitations include sample size which exceeded the 60% response rate,23 but could limit the scope of barriers in written responses. While piloted for understanding and response levels chosen anticipating clinician reluctance to acknowledge lack of competence,26 survey response and recall bias are still possible. Finally, analysis of respondent characteristics was impossible because identifying data was not recorded to ensure anonymity.